Prior Authorization Drug List for 2021* Brand Name Generic Name Therapeutic Category AMPHOTERICIN B LIPID INJ SUSP (FOR IV ABELCET INJ 5MG/ML INFUSION) 5 MG/ML ANTI-INFECTIVES ABIRATERONE TAB 250MG ABIRATERONE ACETATE TAB 250 MG ANTINEOPLASTIC AGENTS ACETYLCYST SOL 10% ACETYLCYSTEINE INHAL SOLN 10% RESPIRATORY ACETYLCYST SOL 20% ACETYLCYSTEINE INHAL SOLN 20% RESPIRATORY ACITRETIN CAP 10MG ACITRETIN CAP 10 MG TOPICAL ACITRETIN CAP 17.5MG ACITRETIN CAP 17.5 MG TOPICAL ACITRETIN CAP 25MG ACITRETIN CAP 25 MG TOPICAL INTERFERON GAMMA-1B INJ 100 MCG/0.5ML ACTIMMUNE INJ 2MU/0.5 (2000000 UNIT/0.5ML) IMMUNOLOGIC AGENTS ACYCLOVIR NA INJ 50MG/ML ACYCLOVIR SODIUM IV SOLN 50 MG/ML ANTI-INFECTIVES ADEMPAS TAB 0.5MG RIOCIGUAT TAB 0.5 MG CARDIOVASCULAR ADEMPAS TAB 1.5MG RIOCIGUAT TAB 1.5 MG CARDIOVASCULAR ADEMPAS TAB 1MG RIOCIGUAT TAB 1 MG CARDIOVASCULAR ADEMPAS TAB 2.5MG RIOCIGUAT TAB 2.5 MG CARDIOVASCULAR ADEMPAS TAB 2MG RIOCIGUAT TAB 2 MG CARDIOVASCULAR AFINITOR DIS TAB 2MG EVEROLIMUS TAB FOR ORAL SUSP 2 MG ANTINEOPLASTIC AGENTS AFINITOR DIS TAB 3MG EVEROLIMUS TAB FOR ORAL SUSP 3 MG ANTINEOPLASTIC AGENTS AFINITOR DIS TAB 5MG EVEROLIMUS TAB FOR ORAL SUSP 5 MG ANTINEOPLASTIC AGENTS AFINITOR TAB 10MG EVEROLIMUS TAB 10 MG ANTINEOPLASTIC AGENTS ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO- AIMOVIG INJ 140MG/ML INJECTOR 140 MG/ML CENTRAL NERVOUS SYSTEM ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO- AIMOVIG INJ 70MG/ML INJECTOR 70 MG/ML CENTRAL NERVOUS SYSTEM ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 ALBUTEROL NEB 0.083% MG/3ML) RESPIRATORY ALBUTEROL NEB 0.5% ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML) RESPIRATORY ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML ALBUTEROL NEB 0.63MG/3 (BASE EQUIV) RESPIRATORY ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML ALBUTEROL NEB 1.25MG/3 (BASE EQUIV) RESPIRATORY ALECENSA CAP 150MG ALECTINIB HCL CAP 150 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTS ALOSETRON TAB 0.5MG ALOSETRON HCL TAB 0.5 MG (BASE EQUIV) GASTROINTESTINAL ALOSETRON TAB 1MG ALOSETRON HCL TAB 1 MG (BASE EQUIV) GASTROINTESTINAL BRIGATINIB TAB INITIATION THERAPY PACK 90 MG ALUNBRIG PAK & 180 MG ANTINEOPLASTIC AGENTS ALUNBRIG TAB 180MG BRIGATINIB TAB 180 MG ANTINEOPLASTIC AGENTS ALUNBRIG TAB 30MG BRIGATINIB TAB 30 MG ANTINEOPLASTIC AGENTS ALUNBRIG TAB 90MG BRIGATINIB TAB 90 MG ANTINEOPLASTIC AGENTS AMBISOME INJ 50MG AMPHOTERICIN B LIPOSOME IV FOR SUSP 50 MG ANTI-INFECTIVES AMBRISENTAN TAB 10MG AMBRISENTAN TAB 10 MG CARDIOVASCULAR AMBRISENTAN TAB 5MG AMBRISENTAN TAB 5 MG CARDIOVASCULAR AMINOSYN-PF INJ 7% *AMINO ACID INFUSION 7%*** NUTRITIONAL/SUPPLEMENTS AMNESTEEM CAP 10MG ISOTRETINOIN CAP 10 MG TOPICAL AMNESTEEM CAP 20MG ISOTRETINOIN CAP 20 MG TOPICAL AMNESTEEM CAP 40MG ISOTRETINOIN CAP 40 MG TOPICAL AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 AMPHET/DEXTR TAB 10MG MG CENTRAL NERVOUS SYSTEM AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 AMPHET/DEXTR TAB 12.5MG MG CENTRAL NERVOUS SYSTEM * Effective 01/01/2021 for the Blue MedicareRxSM Value Plus (PDP) Plan AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 AMPHET/DEXTR TAB 15MG MG CENTRAL NERVOUS SYSTEM AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 AMPHET/DEXTR TAB 20MG MG CENTRAL NERVOUS SYSTEM AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 AMPHET/DEXTR TAB 30MG MG CENTRAL NERVOUS SYSTEM AMPHET/DEXTR TAB 5MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG CENTRAL NERVOUS SYSTEM AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 AMPHET/DEXTR TAB 7.5MG MG CENTRAL NERVOUS SYSTEM AMPHOTERICIN INJ 50MG AMPHOTERICIN B FOR IV SOLN 50 MG ANTI-INFECTIVES ENDOCRINE AND ANADROL-50 TAB 50MG OXYMETHOLONE TAB 50 MG METABOLIC ENDOCRINE AND ANDRODERM DIS 2MG/24HR TESTOSTERONE TD PATCH 24HR 2 MG/24HR METABOLIC ENDOCRINE AND ANDRODERM DIS 4MG/24HR TESTOSTERONE TD PATCH 24HR 4 MG/24HR METABOLIC APOKYN INJ 10MG/ML APOMORPHINE HCL SOLN CARTRIDGE 30 MG/3ML CENTRAL NERVOUS SYSTEM APREPITANT CAP 125MG APREPITANT CAPSULE 125 MG GASTROINTESTINAL APREPITANT CAP 40MG APREPITANT CAPSULE 40 MG GASTROINTESTINAL APREPITANT CAP 80MG APREPITANT CAPSULE 80 MG GASTROINTESTINAL APREPITANT CAPSULE THERAPY PACK 80 & 125 APREPITANT PAK 80 & 125 MG GASTROINTESTINAL ALPHA1-PROTEINASE INHIBITOR (HUMAN) FOR IV ARALAST NP INJ 1000MG SOLN 1000 MG RESPIRATORY ALPHA1-PROTEINASE INHIBITOR (HUMAN) FOR IV ARALAST NP INJ 500MG SOLN 500 MG RESPIRATORY ARCALYST INJ 220MG RILONACEPT FOR INJ 220 MG IMMUNOLOGIC AGENTS ARMODAFINIL TAB 150MG ARMODAFINIL TAB 150 MG CENTRAL NERVOUS SYSTEM ARMODAFINIL TAB 200MG ARMODAFINIL TAB 200 MG CENTRAL NERVOUS SYSTEM ARMODAFINIL TAB 250MG ARMODAFINIL TAB 250 MG CENTRAL NERVOUS SYSTEM ARMODAFINIL TAB 50MG ARMODAFINIL TAB 50 MG CENTRAL NERVOUS SYSTEM ENDOCRINE AND AURYXIA TAB 210MG FERRIC CITRATE TAB 1 GM (210 MG FERRIC IRON) METABOLIC AUSTEDO TAB 12MG DEUTETRABENAZINE TAB 12 MG CENTRAL NERVOUS SYSTEM AUSTEDO TAB 6MG DEUTETRABENAZINE TAB 6 MG CENTRAL NERVOUS SYSTEM AUSTEDO TAB 9MG DEUTETRABENAZINE TAB 9 MG CENTRAL NERVOUS SYSTEM AVITA CRE 0.025% TRETINOIN CREAM 0.025% TOPICAL AVITA GEL 0.025% TRETINOIN GEL 0.025% TOPICAL AYVAKIT TAB 100MG AVAPRITINIB TAB 100 MG ANTINEOPLASTIC AGENTS AYVAKIT TAB 200MG AVAPRITINIB TAB 200 MG ANTINEOPLASTIC AGENTS AYVAKIT TAB 300MG AVAPRITINIB TAB 300 MG ANTINEOPLASTIC AGENTS AZATHIOPRINE TAB 50MG AZATHIOPRINE TAB 50 MG IMMUNOLOGIC AGENTS BALVERSA TAB 3MG ERDAFITINIB TAB 3 MG ANTINEOPLASTIC AGENTS BALVERSA TAB 4MG ERDAFITINIB TAB 4 MG ANTINEOPLASTIC AGENTS BALVERSA TAB 5MG ERDAFITINIB TAB 5 MG ANTINEOPLASTIC AGENTS BANZEL SUS 40MG/ML RUFINAMIDE SUSP 40 MG/ML CENTRAL NERVOUS SYSTEM BANZEL TAB 200MG RUFINAMIDE TAB 200 MG CENTRAL NERVOUS SYSTEM BANZEL TAB 400MG RUFINAMIDE TAB 400 MG CENTRAL NERVOUS SYSTEM BENLYSTA INJ 120MG BELIMUMAB FOR IV SOLN 120 MG IMMUNOLOGIC AGENTS BELIMUMAB SUBCUTANEOUS SOLUTION AUTO- BENLYSTA INJ 200MG/ML INJECTOR 200 MG/ML IMMUNOLOGIC AGENTS BELIMUMAB SUBCUTANEOUS SOLUTION BENLYSTA INJ 200MG/ML PREFILLED SYRINGE 200 MG/ML IMMUNOLOGIC AGENTS BENLYSTA INJ 400MG BELIMUMAB FOR IV SOLN 400 MG IMMUNOLOGIC AGENTS BENZTROPINE TAB 0.5MG BENZTROPINE MESYLATE TAB 0.5 MG CENTRAL NERVOUS SYSTEM BENZTROPINE TAB 1MG BENZTROPINE MESYLATE TAB 1 MG CENTRAL NERVOUS SYSTEM BENZTROPINE TAB 2MG BENZTROPINE MESYLATE TAB 2 MG CENTRAL NERVOUS SYSTEM C1 ESTERASE INHIBITOR (HUMAN) FOR IV INJ KIT BERINERT INJ 500UNIT 500 UNIT HEMATOLOGIC BETASERON INJ 0.3MG INTERFERON BETA-1B FOR INJ KIT 0.3 MG CENTRAL NERVOUS SYSTEM BEXAROTENE CAP 75MG BEXAROTENE CAP 75 MG ANTINEOPLASTIC AGENTS IMMUNE GLOBULIN (HUMAN) IV SOLN 5 BIVIGAM INJ 10% GM/50ML IMMUNOLOGIC AGENTS BOSENTAN TAB 125MG BOSENTAN TAB 125 MG CARDIOVASCULAR BOSENTAN TAB 62.5MG BOSENTAN TAB 62.5 MG CARDIOVASCULAR BOSULIF TAB 100MG BOSUTINIB TAB 100 MG ANTINEOPLASTIC AGENTS BOSULIF TAB 400MG BOSUTINIB TAB 400 MG ANTINEOPLASTIC AGENTS BOSULIF TAB 500MG BOSUTINIB TAB 500 MG ANTINEOPLASTIC AGENTS BRAFTOVI CAP 75MG ENCORAFENIB CAP 75 MG ANTINEOPLASTIC AGENTS BRIVIACT INJ 50MG/5ML BRIVARACETAM IV SOLN 50 MG/5ML CENTRAL NERVOUS SYSTEM BRIVIACT SOL 10MG/ML BRIVARACETAM ORAL SOLN 10 MG/ML CENTRAL NERVOUS SYSTEM BRIVIACT TAB 100MG BRIVARACETAM TAB 100 MG CENTRAL NERVOUS SYSTEM BRIVIACT TAB 10MG BRIVARACETAM TAB 10 MG CENTRAL NERVOUS SYSTEM BRIVIACT TAB 25MG BRIVARACETAM TAB 25 MG CENTRAL NERVOUS SYSTEM BRIVIACT TAB 50MG BRIVARACETAM TAB 50 MG CENTRAL NERVOUS SYSTEM BRIVIACT TAB 75MG BRIVARACETAM TAB 75 MG CENTRAL NERVOUS SYSTEM BRUKINSA CAP 80MG ZANUBRUTINIB CAP 80 MG ANTINEOPLASTIC AGENTS BUDESONIDE SUS 0.25MG/2 BUDESONIDE INHALATION SUSP 0.25 MG/2ML RESPIRATORY BUDESONIDE SUS 0.5MG/2 BUDESONIDE INHALATION SUSP 0.5 MG/2ML RESPIRATORY BUPRENORPHIN SUB 2MG BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV) CENTRAL NERVOUS SYSTEM BUPRENORPHIN SUB 8MG BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV) CENTRAL NERVOUS SYSTEM CABOZANTINIB S-MALATE TAB 20 MG (BASE CABOMETYX TAB 20MG EQUIVALENT) ANTINEOPLASTIC AGENTS CABOZANTINIB S-MALATE TAB 40 MG (BASE CABOMETYX TAB 40MG EQUIVALENT) ANTINEOPLASTIC AGENTS CABOZANTINIB S-MALATE TAB 60 MG (BASE CABOMETYX TAB 60MG EQUIVALENT) ANTINEOPLASTIC AGENTS CALCIPOTRIEN CRE 0.005% CALCIPOTRIENE CREAM 0.005% TOPICAL CALCIPOTRIEN OIN 0.005% CALCIPOTRIENE OINT 0.005% TOPICAL CALCIPOTRIEN SOL 0.005% CALCIPOTRIENE SOLN 0.005% (50 MCG/ML) TOPICAL ENDOCRINE AND CALCITONIN SPR 200/ACT CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT METABOLIC CALCITRENE OIN 0.005% CALCIPOTRIENE OINT 0.005% TOPICAL ENDOCRINE AND CALCITRIOL CAP 0.25MCG CALCITRIOL CAP 0.25 MCG METABOLIC ENDOCRINE AND CALCITRIOL CAP 0.5MCG CALCITRIOL CAP 0.5 MCG METABOLIC ENDOCRINE AND CALCITRIOL INJ 1MCG/ML CALCITRIOL INJ 1 MCG/ML METABOLIC ENDOCRINE AND CALCITRIOL SOL 1MCG/ML CALCITRIOL ORAL SOLN 1 MCG/ML METABOLIC CALQUENCE CAP 100MG ACALABRUTINIB CAP 100 MG ANTINEOPLASTIC AGENTS CAPRELSA TAB 100MG VANDETANIB TAB 100 MG ANTINEOPLASTIC AGENTS CAPRELSA TAB 300MG VANDETANIB TAB 300 MG ANTINEOPLASTIC AGENTS ENDOCRINE AND CARBAGLU TAB 200MG CARGLUMIC ACID TAB 200 MG METABOLIC AZTREONAM LYSINE FOR INHAL SOLN 75 MG CAYSTON INH 75MG (BASE EQUIVALENT) ANTI-INFECTIVES ELIGLUSTAT TARTRATE CAP 84 MG (BASE ENDOCRINE AND CERDELGA CAP 84MG EQUIVALENT) METABOLIC VARENICLINE TARTRATE TAB 0.5 MG X 11 & TAB 1 CHANTIX PAK 0.5& 1MG MG X 42 PACK CENTRAL NERVOUS SYSTEM CHANTIX PAK 1MG VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV) CENTRAL NERVOUS SYSTEM CHANTIX TAB 0.5MG VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV) CENTRAL NERVOUS SYSTEM CHANTIX TAB 1MG VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV) CENTRAL NERVOUS SYSTEM ENDOCRINE AND CINACALCET TAB 30MG CINACALCET HCL TAB 30 MG (BASE EQUIV) METABOLIC CINACALCET TAB 60MG CINACALCET HCL TAB 60 MG (BASE EQUIV) ENDOCRINE AND METABOLIC ENDOCRINE AND CINACALCET TAB 90MG CINACALCET HCL TAB 90 MG (BASE EQUIV) METABOLIC CLARAVIS CAP 10MG ISOTRETINOIN CAP 10 MG TOPICAL CLARAVIS