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Drugs Requiring Prior Authorization for Medical Necessity
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Category Drugs Requiring Prior Formulary Options, Drug Class Authorization for Medical. Necessity 1, Hormonal Agents, Antiandrogens, Cardiovascular TRICOR fenofibrate fenofibric acid. Antilipemics, Cardiovascular ADVICOR atorvastatin fluvastatin lovastatin pravastatin rosuvastatin simvastatin VYTORIN. Antilipemics ALTOPREV, HMG CoA Reductase Inhibitors CRESTOR. HMGs or Statins LESCOL XL, Combinations LIPITOR, Cardiovascular KLOR CON 25 potassium chloride liquid.
Potassium Supplements, Cardiovascular Pulmonary OPSUMIT LETAIRIS PA SP TRACLEER PA SP. Arterial Hypertension Agents, Endothelin, Receptor Antagonists. Carnitine Deficiency Agents CARNITOR levocarnitine. CARNITOR SF, Chronic Obstructive Pulmonary INCRUSE ELLIPTA SPIRIVA. Disease COPD TUDORZA, Anticholinergics, Cystic Fibrosis TOBI tobramycin inhalation solution PA SP BETHKIS PA SP. Inhaled Antibiotics TOBI PODHALER, Depression venlafaxine ext rel tablet duloxetine venlafaxine venlafaxine ext rel capsule PRISTIQ.
Antidepressants Selective except 225 mg, Norepinephrine Reuptake CYMBALTA. Inhibitors SNRIs, Depression OLEPTRO trazodone, Antidepressants. Miscellaneous Agents, Depression Schizophrenia ABILIFY aripiprazole clozapine olanzapine quetiapine risperidone ziprasidone LATUDA SEROQUEL XR. Antipsychotics Atypicals, Dermatology fluorouracil cream 0 5 fluorouracil cream 5 fluorouracil solution imiquimod PICATO ZYCLARA. Actinic Keratosis CARAC, Dermatology NORITATE metronidazole sulfacetamide sulfur FINACEA SOOLANTRA.
Dermatology clobetasol spray clobetasol foam, Skin Inflammation and Hives CLOBEX SPRAY. Corticosteroids OLUX E, APEXICON E desoximetasone fluocinonide. Dermatology ALCORTIN A hydrocortisone, Miscellaneous Skin Conditions ALOQUIN. Diabetes FORTAMET metformin metformin ext rel, Biguanides GLUMETZA. Diabetes NESINA JANUVIA TRADJENTA, Dipeptidyl Peptidase 4 ONGLYZA.
DPP 4 Inhibitors, Diabetes KAZANO JANUMET JANUMET XR JENTADUETO JENTADUETO XR. Dipeptidyl Peptidase 4 KOMBIGLYZE XR, DPP 4 Inhibitor Combinations OSENI. Category Drugs Requiring Prior Formulary Options, Drug Class Authorization for Medical. Necessity 1, Diabetes BYDUREON TRULICITY SI VICTOZA SI. Injectable Incretin Mimetics BYETTA, Diabetes APIDRA NOVOLOG.
Insulins HUMALOG, HUMALOG MIX 50 50 NOVOLOG MIX 70 30. HUMALOG MIX 75 25 NOVOLOG MIX 70 30, HUMULIN 70 30 2 NOVOLIN 70 30 2. HUMULIN N 2 NOVOLIN N 2, HUMULIN R 2 NOVOLIN R 2, NOTE Humulin R U. 500 concentrate vial will not be, subject to prior authorization and. will continue to be covered, Diabetes LANTUS BASAGLAR LEVEMIR TRESIBA.
Long Acting Insulins TOUJEO, Diabetes ACTOS pioglitazone. Insulin Sensitizers, Diabetes INVOKANA FARXIGA JARDIANCE. Sodium Glucose, Co transporter 2 SGLT2, Inhibitors. Diabetes INVOKAMET XIGDUO XR, Sodium Glucose, Co transporter 2 SGLT2. Inhibitor Biguanide, Combinations, Diabetes ALLISON MEDICAL PEN BD PEN NEEDLES.
Supplies Pen Needles NEEDLES, NOVO NORDISK PEN NEEDLES. ULTIMED PEN NEEDLES, All other insulin pen needles that. are not BD brand, Diabetes ALLISON MEDICAL BD INSULIN SYRINGES. Supplies Syringes INSULIN SYRINGES, TRIVIDIA INSULIN SYRINGES. ULTIMED INSULIN SYRINGES, All other insulin syringes that are.
not BD brand, Diabetes ACCU CHEK STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS 3 ONETOUCH VERIO STRIPS AND KITS 3. Supplies Test Strips and Kits 3 BREEZE 2 STRIPS AND KITS. 4 CONTOUR NEXT STRIPS AND, CONTOUR STRIPS AND KITS. FREESTYLE STRIPS AND KITS, All other test strips that are not. ONETOUCH brand, Erectile Dysfunction LEVITRA CIALIS QL. Phosphodiesterase Inhibitors VIAGRA, Gastrointestinal Agents RELISTOR MOVANTIK.
Opioid induced Constipation, Gastrointestinal Agents NEXIUM esomeprazole lansoprazole omeprazole omeprazole sodium bicarbonate capsule pantoprazole DEXILANT. Proton Pump Inhibitors PPIs PREVACID, Category Drugs Requiring Prior Formulary Options. Drug Class Authorization for Medical, Necessity 1, Glaucoma LUMIGAN latanoprost travoprost TRAVATAN Z ZIOPTAN. Prostaglandin Analogs, Growth Hormones GENOTROPIN HUMATROPE PA SP SI NORDITROPIN PA SP SI. NUTROPIN AQ, Hematologic PRADAXA warfarin ELIQUIS XARELTO.
Anticoagulants oral, Hematologic NEUPOGEN ZARXIO PA SP SI. Neutropenia Colony Stimulating, Hematologic PLAVIX clopidogrel BRILINTA EFFIENT. Platelet Aggregation Inhibitors, High Blood Pressure ATACAND candesartan eprosartan irbesartan losartan telmisartan valsartan BENICAR. Angiotensin II Receptor DIOVAN, Antagonists EDARBI. High Blood Pressure ATACAND HCT candesartan hydrochlorothiazide irbesartan hydrochlorothiazide losartan hydrochlorothiazide telmisartan. Angiotensin II Receptor DIOVAN HCT hydrochlorothiazide valsartan hydrochlorothiazide BENICAR HCT. Antagonist Diuretic EDARBYCLOR, Combinations TEVETEN HCT.
High Blood Pressure EXFORGE amlodipine telmisartan amlodipine valsartan AZOR. Angiotensin II Receptor, Antagonist Calcium Channel. Blocker Combinations, High Blood Pressure EXFORGE HCT amlodipine valsartan hydrochlorothiazide TRIBENZOR. Angiotensin II Receptor, Antagonist Calcium Channel. Blocker Diuretic Combinations, High Blood Pressure DUTOPROL metoprolol succinate ext rel WITH hydrochlorothiazide. Beta blocker Combinations, High Blood Pressure NORVASC amlodipine.
Calcium Channel Blockers, CARDIZEM diltiazem ext rel except generic of CARDIZEM LA. CARDIZEM CD, CARDIZEM LA and its generics, Huntington s Disease Agents XENAZINE tetrabenazine PA SP. Inflammatory Bowel Disease ASACOL HD balsalazide sulfasalazine sulfasalazine delayed rel APRISO LIALDA PENTASA UCERIS. IBD Ulcerative Colitis DELZICOL, Aminosalicylates, Kidney Disease FOSRENOL calcium acetate PHOSLYRA RENVELA VELPHORO. Phosphate Binders, Multiple Sclerosis Agents AVONEX glatiramer PA SP SI AUBAGIO PA SP BETASERON PA SP SI COPAXONE 40 MG PA SP SI. EXTAVIA GILENYA PA SP REBIF PA SP SI TECFIDERA PA SP. Musculoskeletal Agents AMRIX cyclobenzaprine, Opioid Dependence Agents ZUBSOLV buprenorphine naloxone sublingual tablet SUBOXONE FILM.
Opioid Reversal Agents EVZIO NARCAN NASAL SPRAY, Overactive Bladder DETROL LA oxybutynin ext rel tolterodine tolterodine ext rel trospium trospium ext rel MYRBETRIQ TOVIAZ. Incontinence ENABLEX VESICARE, Urinary Antispasmodics GELNIQUE. Category Drugs Requiring Prior Formulary Options, Drug Class Authorization for Medical. Necessity 1, Pain butalbital acetaminophen caffeine naratriptan QL rizatriptan QL sumatriptan QL zolmitriptan QL RELPAX QL ZOMIG NASAL SPRAY QL. Headache Agents capsule, Pain ABSTRAL fentanyl transmucosal lozenge PA FENTORA PA SUBSYS PA.
Transmucosal Immediate, release Fentanyl Agents, Pain and Inflammation DEXPAK dexamethasone methylprednisolone prednisone. Corticosteroids MILLIPRED, Pain and Inflammation ARTHROTEC celecoxib diclofenac sodium meloxicam or naproxen WITH esomeprazole lansoprazole omeprazole. Nonsteroidal Anti inflammatory omeprazole sodium bicarbonate capsule pantoprazole or DEXILANT. Drugs NSAIDs Combinations, PENNSAID diclofenac sodium diclofenac sodium solution meloxicam naproxen VOLTAREN GEL. NAPRELAN celecoxib diclofenac sodium meloxicam naproxen. Prostate Condition JALYN dutasteride or finasteride WITH alfuzosin ext rel doxazosin tamsulosin terazosin or RAPAFLO. Benign Prostatic Hyperplasia, Agents Combinations, Sleep INTERMEZZO eszopiclone zolpidem zolpidem ext rel SILENOR. Hypnotics Non LUNESTA, benzodiazepines ROZEREM, Testosterone Replacement testosterone gel 1 5 ANDRODERM AXIRON.
Androgens ANDROGEL, Category Formulary Options, Drug Class. Autoimmune and Hepatitis C For Autoimmune and Hepatitis C CVS Caremark will be implementing an Indication Based Formulary for 2017 which may result in additional. exclusions announced in both classes, Generics Limited source generics may be evaluated when appropriate and potentially excluded. Hyperinflation Products with significant cost inflation throughout the year may be evaluated and potentially excluded. New to Market Agents 1 New to market products and new variations of products already in the marketplace will not be added to the formulary until the product has been. evaluated determined to be clinically appropriate and cost effective and approved by the CVS Caremark 6 Pharmacy and Therapeutics Committee. or other appropriate reviewing body, Specialty As new specialty products launch all existing products in the class will be re evaluated to determine appropriate formulary placement and potentially. excluded added back to formulary or not listed, The listed formulary options are subject to change. List of Drugs Requiring Prior Authorization for Medical Necessity 1. ABILIFY HUMALOG OXYTROL, ABSTRAL HUMALOG MIX 50 50 PENNSAID.
ACCU CHEK STRIPS AND KITS 4 HUMALOG MIX 75 25 PLAVIX. ACTOS HUMULIN 70 30 2 PLEGRIDY, ADDERALL XR HUMULIN N 2 PRADAXA. ADRENACLICK HUMULIN R 2 PREVACID, ADVICOR INCRUSE ELLIPTA PROTONIX. AEROSPAN INTERMEZZO PROVENTIL HFA, ALCORTIN A INTUNIV QNASL. ALLISON MEDICAL INSULIN SYRINGES INVOKAMET QSYMIA, ALLISON MEDICAL PEN NEEDLES INVOKANA RAYOS. ALOQUIN JALYN RELISTOR, ALTOPREV KAZANO RHINOCORT AQUA.
ALVESCOAMRIX KLOR CON 25 RIOMET, ANDROGEL KOMBIGLYZE XR ROZEREM. APEXICON E LANTUS SAIZEN, APIDRA LASTACAFT SYMBICORT. ARTHROTEC LESCOL XL TASIGNA, ASACOL HD LEVITRA TECHNIVIE. ATACAND LIPITOR TESTIM, ATACAND HCT LIPTRUZET testosterone gel 1 5. AVONEX LIVALO TEVETEN, BECONASE AQ LUMIGAN TEVETEN HCT.
BREEZE 2 STRIPS AND KITS 4 LUNESTA TOBI, butalbital acetaminophen caffeine capsule Matzim LA TOBI PODHALER. BYDUREON MILLIPRED TOUJEO, BYETTA NAPRELAN TRICOR, CARAC NATESTO TRIVIDIA INSULIN SYRINGES. CARDIZEM NESINA TUDORZA, CARDIZEM CD NEUPOGEN ULTIMED INSULIN SYRINGES. CARDIZEM LA and its generics NEXIUM ULTIMED PEN NEEDLES. CARNITOR NILANDRON VALCYTE, CARNITOR SF NORITATE VALTREX. clobetasol spray NORVASC venlafaxine ext rel tablets except for 225 mg. CLOBEX SPRAY NOVACORT VENTOLIN HFA, CONTOUR NEXT STRIPS AND KITS 4 NOVO NORDISK PEN NEEDLES VERAMYST.
CONTOUR STRIPS AND KITS 4 NUTROPIN AQ VIAGRA, CRESTOR OLEPTRO VIEKIRA PAK. CYMBALTA OLUX E, DAKLINZA OLYSIO VOGELXO, DELZICOL OMNARIS XENAZINE. DETROL LA OMNITROPE XOPENEX HFA, DEXPAK ONGLYZA XTANDI. DIOVAN OPSUMIT ZEGERID, DIOVAN HCT OSENI ZEPATIER, DUTOPROL ZUBSOLV. EDARBYCLOR, EXFORGE HCT, fluorouracil cream 0 5, FREESTYLE STRIPS AND KITS 4.
GENOTROPIN, This list represents brand products in CAPS branded generics in upper and lowercase Italics and generic products in lowercase italics This is not an all. inclusive list of available covered options To learn more about your specific drug benefit log into My Account at www carefirst com myaccount and click on. Drug Pharmacy Resources under Quick Links or call CareFirst Pharmacy Services at 800 241 3371 Discuss this information with your doctor or health care. provider This information is not a substitute for medical advice or treatment Talk to your doctor or health care provider about this information and any health. related questions you have CareFirst and CVS Caremark assume no liability whatsoever for the information provided or for any diagnosis or treatment made as. a result of this information This list is subject to change There may be additional plan restrictions Please consult your plan for further information. Subject to applicable laws and regulations, This list indicates the common uses for which the drug is prescribed Some drugs are prescribed for more than one condition. PAPrior authorization required for prescription benefits coverage. QLQuantity limits, SI Self injectable product, SP Specialty product. 1 If your doctor believes you have a specific clinical need for one of these products he or she should contact the Prior Authorization department at 855 240. 2 Rebranded or private label formulations are not covered without a prior authorization for medical necessity i e RELION. 3 A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information on how to obtain a blood glucose meter call 800 588 4456. 4 ONETOUCH brand test strips are the only preferred options. 5 Listing reflects the authorized generics for TESTIM and VOGELXO. 6 CVS Caremark is an independent company that provides pharmacy benefit management services. Your privacy is important to us CVS Caremark employees are trained regarding the appropriate way to handle your private health information. This document contains confidential and proprietary information of CareFirst and CVS Caremark and cannot be reproduced distributed or printed without written. permission from CareFirst CareFirst may receive rebates discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated. with CareFirst or CVS Caremark Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor. CareFirst of Maryland Inc Group Hospitalization and Medical Services Inc First Care Inc and. CareFirst BlueChoice Inc are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered tra. Drugs Requiring Prior Authorization for Medical Necessity for CareFirst Formulary 2 Effective January 1 2017 Below is a list of additional drugs that require a medical necessity prior authorization before they are covered by your CareFirst

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