VIRGINIA PREMIER ELITE PLUS PRIOR AUTHORIZATION DETAIL October 1, 2021 GENERAL DISCLAIMER: Virginia Premier does not recognize the use of drug samples to meet clinical criteria requirements for prior drug use for drugs covered under the pharmacy benefit or drugs administered in the physician office or other outpatient setting. A physician’s statement that samples have been used cannot be used as documentation of prior drug use. Non-Preferred products are subject to service authorization which requires trial and failure of two preferred products. Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval. Table of Contents ABACAVIR (GENERIC ZIAGEN) ..................................................................................................................... 12 ABILIFY (ARIPIPRAZOLE) ............................................................................................................................. 12 ABUSE DETERRENT OPIOID (ARYMO, HYSINGLA, MORPHABOND, ZOHYDRO, OXAYDO, EMBEDA, ROXYBOND, XTAMPZA)............................................................................................................... 13 ACNE AGE LIMIT............................................................................................................................................... 15 ACCRUFER (FERRIC MALTOL)...................................................................................................................... 16 ACTEMRA (TOCILIZUMAB) ........................................................................................................................... 16 ACTIQ (FENTANYL CITRATE) LOZENGE .................................................................................................... 17 ACTHAR HP (REPOSITORY CORTICOTROPIN) ........................................................................................ 18 ACZONE (DAPSONE)........................................................................................................................................ 19 ADEMPAS (RIOCIGUAT) ................................................................................................................................. 19 ADHD AGE LIMIT ............................................................................................................................................. 20 AEMCOLO (RIFAMYCIN) ................................................................................................................................. 21 AFINITOR (EVEROLIMUS) ............................................................................................................................. 22 ALFERON N (INTERFERON ALFA-N3)......................................................................................................... 23 ALOXI (PALONOSETRON) .............................................................................................................................. 23 AMITIZA (LUBIPROSTONE) .......................................................................................................................... 24 AMPYRA (DALFAMPRIDINE) ........................................................................................................................ 24 AKLlEF (TRIFAROTENE) ................................................................................................................................ 26 Anti-Migraine Non-preferred (AIMOVIG, EMGALITY 100 MG SYRINGE, NURTEC ODT, REYVOW) .............................................................................................................................................................................. 26 ANTI-MIGRAINE PREFERRED (EMGALITY PEN AND SYRINGE 120 MG, AJOVY, UBRELVY) ........ 27 ANTIPSYCHOTICS < 18 YEARS OF AGE....................................................................................................... 27 ANZEMET (DOLASETRON MESYLATE) VIAL............................................................................................. 28 ARCALYST (RILONACEPT)............................................................................................................................. 28 AREDIA (PAMIDRONATE DISODIUM) ........................................................................................................ 29 ARIKAYCE (AMIKACIN SULFATE)................................................................................................................ 30 ATRIPLA (EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE) ........................ 31 AUBAGIO (TERIFLUNOMIDE) ....................................................................................................................... 31 AURYXIA (FERRIC CITRATE) ........................................................................................................................ 32 AUSTEDO (DEUTETRABENAZINE) .............................................................................................................. 33 AUVI-Q (EPINEPHRINE) ................................................................................................................................. 33 AVASTIN (BEVACIZUMAB) ............................................................................................................................ 34 AVSOLA, REMICADE, INFLECTRA (INFLIXIMAB)..................................................................................... 36 AYVAKIT (AVAPRITINIB) .............................................................................................................................. 37 BANZEL (RUFINAMIDE) ................................................................................................................................. 37 BELBUCA (BUPRENOPRHINE FILM) ........................................................................................................... 38 BEOVU (BROLUCIZUMAB-DBLL) ................................................................................................................. 40 Requests for continuing therapy that were approved by a previous Health Plan will be honored for at least 30 days upon receipt of documentation demonstrating that approval. BONIVA (IBANDRONATE) SYRINGE............................................................................................................ 40 BOTOX (ONABOTULINUMTOXINA) ............................................................................................................ 41 BRUKINSA (ZANUBRUTINIB) ....................................................................................................................... 45 BUPRENORPHINE (GENERIC BUPRENEX, GENERIC SUBUTEX) ........................................................... 45 BUTORPHANOL (GENERIC STADOL) .......................................................................................................... 47 CABENUVA (CABOTEGRAVIR/RILPIVIRINE)......................................................................................................... 47 CABLIVI (CAPLACIZUMAB-yhdp) ................................................................................................................ 48 CALQUENCE (ACALABRUTINIB) .................................................................................................................. 48 CAPLYTA (LUMATEPERONE)........................................................................................................................ 49 CARIMUNE NF (IMMUNE GLOBULIN, HUMAN INTRAVENOUS) ........................................................... 50 CARISOPRODOL TABLET (SOMA) ............................................................................................................... 53 CELEBREX (CELECOXIB) STEP THERAPY .......................................................................................... 53 CHENODAL (CHENODIOL) ............................................................................................................................. 53 CIALIS (TADALAFIL ) 5MG ONLY ................................................................................................................. 54 CIMZIA (CERTOLIZUMAB PEGOL) ............................................................................................................... 54 CINQAIR (RESLIZUMAB) ................................................................................................................................ 57 COMBIVIR (LAMIVUDINE/ZIDOVUDINE) .................................................................................................. 57 COMPLERA (EMTRICITABINE/RILPIVIRINE/TENOFOVIR DISOPROXIL FUMARATE) .................. 58 COMPOUNDED MEDICATIONS ..................................................................................................................... 58 COPEGUS (RIBAVIRIN) ................................................................................................................................... 63 CORLANOR (IVABRADINE)............................................................................................................................ 67 COSENTYX (SECUKINUMAB)......................................................................................................................... 67 CRESEMBA (ISAVUCONAZONIUM)......................................................................................................... 70 CRYSVITA (BUROSUMAB-TWZA) ................................................................................................................ 70 CUMULATIVE MED GREATER