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2021 prior authorization drug list

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2021 Prior Authorization Drug List This is a list of medications that will not be covered without a prior authorization for medical necessity, effective January 1, 2021. ABECMA ABILIFY MAINTENA abiraterone acetate ACCRUFER accutane ACTHAR ACTIMMUNE ACTIQ ADAGEN ADAKVEO ADASUVE ADCETRIS ADCIRCA ADDYI adefovir dipivoxil ADEMPAS ADIPEX-P ADLYXIN STARTER PACK ADLYXIN AEMCOLO AFINITOR DISPERZ AFINITOR AIMOVIG (140 MG DOSE) AIMOVIG AIRDUO DIGIHALER AJOVY AKYNZEO ALDURAZYME ALECENSA ALINIA ALIQOPA ALKERAN alosetron hcl ALOXI ALUNBRIG alyq ambrisentan AMELUZ AMITIZA amnesteem AMONDYS 45 AMPYRA AMVISC PLUS AMVISC ANDRODERM ANDROGEL ANDROID ANZEMET APOKYN aprepitant ARALAST NP ARANESP (ALBUMIN FREE) ARCALYST ARIKAYCE ARISTADA INITIO ARISTADA armodafinil ARMONAIR DIGIHALER ARZERRA ASCENIV ASPARLAS AUBAGIO AUSTEDO AVEED AVONEX PEN AVONEX PREFILLED AVONEX AVSOLA AYVAKIT azacitidine BAFIERTAM BALVERSA BARACLUDE BARHEMSYS BAVENCIO BAXDELA BELBUCA BELRAPZO BELVIQ XR BELVIQ BENDAMUSTINE HCL BENDEKA BENLYSTA BENZPHETAMINE HCL BEOVU BERINERT BESPONSA BETASERON BETHKIS BEVACIZUMAB BEVYXXA bexarotene BIOLON BIVIGAM BLENREP BLINCYTO BONIVA BORTEZOMIB bosentan BOSULIF BOTOX BRAFTOVI BREXAFEMME BREYANZI BRIDION BRINEURA BRONCHITOL TOLERANCE TEST BRONCHITOL BRUKINSA BUPHENYL BUTORPHANOL TARTRATE BYLVAY (PELLETS) BYLVAY BYNFEZIA PEN CABLIVI CABOMETYX calcipotriene-betameth diprop CAMPATH capecitabine CAPRELSA CARBAGLU CARIMUNE NF CAROSPIR CAYSTON CEQUA CERDELGA CEREZYME CESAMET CETROTIDE CHENODAL CHOLBAM cinacalcet hcl CINQAIR CINRYZE CINVANTI claravis COMETRIQ (100 MG DAILY DOSE) COMETRIQ (140 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) CONTRAVE COPEGUS COPIKTRA CORLANOR COSELA COSENTYX (300 MG DOSE) COSENTYX SENSOREADY (300 MG) COSENTYX SENSOREADY PEN COSENTYX COTELLIC CRESEMBA CRYSVITA CUPRIMINE CUVITRU CYCLOSPORINE IN KLARITY CYRAMZA CYSTADROPS CYSTAGON CYSTARAN DACOGEN dalfampridine er DALIRESP DANYELZA DARAPRIM DARZALEX FASPRO DARZALEX DAURISMO deferasirox granules deferasirox deferiprone deferoxamine mesylate DEFITELIO DEMSER DESFERAL DESOXYN DEXTENZA dextroamphetamine sulfate DEXYCU di-phen DIACOMIT DICLOFENAC EPOLAMINE DIETHYLPROPION HCL ER DIETHYLPROPION HCL DIFICID dimethyl fumarate starter pack DIMETHYL FUMARATE DOJOLVI DOPTELET DOXYCYCLINE HYCLATE DOXYCYCLINE dronabinol DUOVISC DUPIXENT DUROLANE DYSPORT EC-RX TESTOSTERONE EGRIFTA ELAPRASE ELIGARD ELZONRIS EMEND TRI-PACK EMEND EMFLAZA EMGALITY (300 MG DOSE) EMGALITY EMPAVELI EMPLICITI EMSAM ENBREL MINI ENBREL SURECLICK ENBREL ENDARI ENHERTU ENSPRYNG entecavir ENTRESTO ENTYVIO epaned EPCLUSA EPIDIOLEX EPINEPHRINE EPOGEN epoprostenol sodium ERBITUX ERIVEDGE ERLEADA erlotinib hcl ESBRIET ETESEVIMAB EUCRISA EUFLEXXA EVENITY everolimus EVKEEZA EVOMELA EVRYSDI EXJADE EXONDYS 51 EXSERVAN EYLEA EYSUVIS (Continued) The rights of the drug names appearing on this Prior Authorization Drug List, whether or not appearing in connection with the trademark symbol, belong exclusively to their owners. ©2021 WellDyne. All Rights Reserved

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Page 1: 2021 Prior Authorization Drug List

2021 Prior Authorization Drug List

This is a list of medications that will not be covered without a prior authorization for medical necessity, effectiveJanuary 1, 2021.

ABECMAABILIFY MAINTENAabiraterone acetateACCRUFERaccutaneACTHARACTIMMUNEACTIQADAGENADAKVEOADASUVEADCETRISADCIRCAADDYIadefovir dipivoxilADEMPASADIPEX-PADLYXIN STARTER PACKADLYXINAEMCOLOAFINITOR DISPERZAFINITORAIMOVIG (140 MG DOSE)AIMOVIGAIRDUO DIGIHALERAJOVYAKYNZEOALDURAZYMEALECENSAALINIAALIQOPAALKERANalosetron hclALOXIALUNBRIGalyqambrisentanAMELUZAMITIZAamnesteemAMONDYS 45AMPYRAAMVISC PLUSAMVISCANDRODERMANDROGELANDROIDANZEMETAPOKYNaprepitantARALAST NPARANESP (ALBUMIN FREE)ARCALYSTARIKAYCEARISTADA INITIOARISTADAarmodafinilARMONAIR DIGIHALERARZERRAASCENIV

ASPARLASAUBAGIOAUSTEDOAVEEDAVONEX PENAVONEX PREFILLEDAVONEXAVSOLAAYVAKITazacitidineBAFIERTAMBALVERSABARACLUDEBARHEMSYSBAVENCIOBAXDELABELBUCABELRAPZOBELVIQ XRBELVIQBENDAMUSTINE HCLBENDEKABENLYSTABENZPHETAMINE HCLBEOVUBERINERTBESPONSABETASERONBETHKISBEVACIZUMABBEVYXXAbexaroteneBIOLONBIVIGAMBLENREPBLINCYTOBONIVABORTEZOMIBbosentanBOSULIFBOTOXBRAFTOVIBREXAFEMMEBREYANZIBRIDIONBRINEURABRONCHITOL TOLERANCE TESTBRONCHITOLBRUKINSABUPHENYLBUTORPHANOL TARTRATEBYLVAY (PELLETS)BYLVAYBYNFEZIA PENCABLIVICABOMETYXcalcipotriene-betameth dipropCAMPATHcapecitabineCAPRELSA

CARBAGLUCARIMUNE NFCAROSPIRCAYSTONCEQUACERDELGACEREZYMECESAMETCETROTIDECHENODALCHOLBAMcinacalcet hclCINQAIRCINRYZECINVANTIclaravisCOMETRIQ (100 MG DAILY DOSE)COMETRIQ (140 MG DAILY DOSE)COMETRIQ (60 MG DAILY DOSE)CONTRAVECOPEGUSCOPIKTRACORLANORCOSELACOSENTYX (300 MG DOSE)COSENTYX SENSOREADY (300 MG)COSENTYX SENSOREADY PENCOSENTYXCOTELLICCRESEMBACRYSVITACUPRIMINECUVITRUCYCLOSPORINE IN KLARITYCYRAMZACYSTADROPSCYSTAGONCYSTARANDACOGENdalfampridine erDALIRESPDANYELZADARAPRIMDARZALEX FASPRODARZALEXDAURISMOdeferasirox granulesdeferasiroxdeferipronedeferoxamine mesylateDEFITELIODEMSERDESFERALDESOXYNDEXTENZAdextroamphetamine sulfateDEXYCUdi-phenDIACOMITDICLOFENAC EPOLAMINE

DIETHYLPROPION HCL ERDIETHYLPROPION HCLDIFICIDdimethyl fumarate starter packDIMETHYL FUMARATEDOJOLVIDOPTELETDOXYCYCLINE HYCLATEDOXYCYCLINEdronabinolDUOVISCDUPIXENTDUROLANEDYSPORTEC-RX TESTOSTERONEEGRIFTAELAPRASEELIGARDELZONRISEMEND TRI-PACKEMENDEMFLAZAEMGALITY (300 MG DOSE)EMGALITYEMPAVELIEMPLICITIEMSAMENBREL MINIENBREL SURECLICKENBRELENDARIENHERTUENSPRYNGentecavirENTRESTOENTYVIOepanedEPCLUSAEPIDIOLEXEPINEPHRINEEPOGENepoprostenol sodiumERBITUXERIVEDGEERLEADAerlotinib hclESBRIETETESEVIMABEUCRISAEUFLEXXAEVENITYeverolimusEVKEEZAEVOMELAEVRYSDIEXJADEEXONDYS 51EXSERVANEYLEAEYSUVIS

(Continued)

The rights of the drug names appearing on this Prior Authorization Drug List, whether or not appearing in connection with the trademark symbol, belong exclusively to their owners.

©2021 WellDyne. All Rights Reserved

Page 2: 2021 Prior Authorization Drug List

2021 Prior Authorization Drug List

FABRAZYMEFARYDAKFASENRA PENFASENRAFENSOLVI (6 MONTH)FENTANYL CITRATEFERRIPROX TWICE-A-DAYFERRIPROXFINTEPLAFIRAZYRFIRMAGONFIRST-TESTOSTERONE MCFIRST-TESTOSTERONEFLEBOGAMMA DIFFLECTORFLOLANFORTEOFOSAPREPITANT DIMEGLUMINEFOTIVDAFULPHILAFUZEONGALAFOLDGAMASTANGAMIFANTGAMMAGARD S/D LESS IGAGAMMAGARDGAMMAPLEXGAMUNEX-Cganirelix acetateGATTEXGAVRETOGAZYVAGELSYN-3GENOTROPIN MINIQUICKGENOTROPINGEODONGILENYAGILOTRIFGIVLAARIGLASSIAglatiramer acetateglatopaGLEOSTINEGOCOVRIGRANIXHAEGARDAHALAVENHEALON DUET PROHEALON GV PROHEALON GVHEALON PROHEALON5 PROHEALON5HEALONHEMLIBRAHERZUMAHETLIOZ LQHETLIOZHIZENTRAHUMIRA PEDIATRIC CROHNS STARTHUMIRA PEN-CD/UC/HS STARTER

HUMIRA PEN-PEDIATRIC UCSTARTHUMIRA PEN-PS/UV/ADOL HSSTARTHUMIRA PEN-PSOR/UVEITSTARTERHUMIRA PENHUMIRAHYALURONIDASE (INTRAOCULAR)HYCAMTINHYDROXYPROGESTERONECAPROATEHYQVIAibandronate sodiumIBRANCEicatibant acetateICLUSIGIDHIFAILARISILUVIENimatinib mesylateIMBRUVICAIMCIVREEIMFINZIIMLYGICIMPAVIDOINBRIJAINCRELEXINFLECTRAINGREZZAINJECTAFERINLYTAINQOVIINREBICINTRON AINVEGA HAFYERAINVEGA SUSTENNAINVEGA TRINZAIRESSAisotretinoinISOTRETINOINISTODAX (OVERFILL)ISTURISAJADENU SPRINKLEJAKAFIJEMPERLIJEVTANAJIVIJUXTAPIDJYNARQUEKADCYLAKALBITORKALYDECOKANJINTIKANUMAKERENDIAKESIMPTAKEVEYISKEYTRUDAKIMYRSAKISQALI (200 MG DOSE)

KISQALI (400 MG DOSE)KISQALI (600 MG DOSE)KISQALI FEMARA (400 MG DOSE)KISQALI FEMARA (600 MG DOSE)KISQALI FEMARA(200 MG DOSE)KITABIS PAKKLISYRIKORLYMKOSELUGOKRYSTEXXAKUVANKYMRIAHKYNAMROKYNMOBI TITRATION KITKYNMOBIKYPROLISLAMPITlapatinib ditosylateLARTRUVOLAZANDALEMTRADALENVIMA (10 MG DAILY DOSE)LENVIMA (12 MG DAILY DOSE)LENVIMA (14 MG DAILY DOSE)LENVIMA (18 MG DAILY DOSE)LENVIMA (20 MG DAILY DOSE)LENVIMA (24 MG DAILY DOSE)LENVIMA (4 MG DAILY DOSE)LENVIMA (8 MG DAILY DOSE)LETAIRISLEUKINEleuprolide acetateLEUPROLIDE ACETATELEVULAN KERASTICKLIBTAYOLICARTLINZESSLOMAIRALONSURFLORBRENALOREEV XRLUBIPROSTONELUCEMYRALUCENTISLUMAKRASLUMIZYMELUMOXITILUPANETA PACKLUPKYNISLUPRON DEPOT (1-MONTH)LUPRON DEPOT (3-MONTH)LUPRON DEPOT (4-MONTH)LUPRON DEPOT (6-MONTH)LUPRON DEPOT-PED (1-MONTH)LUPRON DEPOT-PED (3-MONTH)LUXTURNALYNPARZALYSODRENMACRILENMACUGENMAKENA

MARGENZAMARINOLMATULANEMAVENCLAD (10 TABS)MAVENCLAD (4 TABS)MAVENCLAD (5 TABS)MAVENCLAD (6 TABS)MAVENCLAD (7 TABS)MAVENCLAD (8 TABS)MAVENCLAD (9 TABS)MAVYRETMAYZENT STARTER PACKMAYZENTMEKINISTMEKTOVImelphalanMEPSEVIImethamphetamine hclMETHITESTMETHYLTESTOSTERONEmetyrosineMIRCERAMIRVASOmitoxantrone hclmodafinilMODERIBA (1000 MG PACK)MODERIBA (1200 MG PACK)MODERIBA (600 MG PACK)MODERIBA (800 MG PACK)moderibaMONJUVIMONOVISCMOTEGRITYMOVANTIKMOZOBILMULPLETAMVASIMYALEPTMYCAPSSAMYFEMBREEMYLERANMYLOTARGMYOBLOCmyorisanNAGLAZYMENATESTONATPARANAYZILAMNERLYNXNEUPOGENNEXAVARNEXLETOLNEXLIZETNEXVIAZYMENINLAROnitazoxanidenitisinoneNITYRNIVESTYMNOCTIVANORDITROPIN FLEXPRO

(Continued)

The rights of the drug names appearing on this Prior Authorization Drug List, whether or not appearing in connection with the trademark symbol, belong exclusively to their owners.

©2021 WellDyne. All Rights Reserved

Page 3: 2021 Prior Authorization Drug List

2021 Prior Authorization Drug List

NORTHERANOURIANZNOXAFILNPLATENUBEQANUCALANUEDEXTANULIBRYNULOJIXNUPLAZIDNURTECNUZYRANYVEPRIAOCALIVAOCREVUSOCTAGAMOCTREOTIDE ACETATEODOMZOOFEVOGIVRIOLINVYKONIVYDEONMELONPATTROONUREGOPDIVOOPSUMITORACEAORBACTIVORENITRAMORFADINORGOVYXORIAHNNORILISSAORKAMBIORLADEYOORTHOVISCOSMOLEX EROTEZLAOVIDRELOXBRYTAOXERVATEOXISTATOXLUMOOZEMPIC (0.25 OR 0.5 MG/DOSE)OZEMPIC (1 MG/DOSE)PADCEVPALONOSETRON HCLPALYNZIQPANZYGAPARSABIVPEG-INTRON REDIPENPEGASYS PROCLICKPEGASYSPEGINTRONPEMAZYREpenicillaminePEPAXTOPERJETAPERSERISPHENDIMETRAZINE TARTRATE ER

phendimetrazine tartratephentermine hclPHENTERMINE HCLPHESGOPHOTOFRINPICATOPIQRAY (200 MG DAILY DOSE)PIQRAY (250 MG DAILY DOSE)PIQRAY (300 MG DAILY DOSE)PLEGRIDY STARTER PACKPLEGRIDYPOLIVYPOMALYSTPONVORY STARTER PACKPONVORYPORTRAZZAposaconazolePOTELIGEOPRALUENTPRETOMANIDPREVYMISPRIVIGENPROBUPHINE IMPLANT KITPROCRITPROCYSBIPROLASTIN-CPROLATEPROLIAPROMACTAPROVENGEPROVISCPULMOZYMEpyrimethaminePYRIMETHAMINEQBRELISQBREXZAQINLOCKQSYMIARADICAVARAPAMUNERASUVORAVICTIRAYALDEEREBETOLREBIF REBIDOSE TITRATION PACKREBIF REBIDOSEREBIF TITRATION PACKREBIFREBLOZYLREGIMEXREGRANEXRELISTORREMICADEREMODULINRENFLEXISREPATHA PUSHTRONEX SYSTEMREPATHA SURECLICKREPATHARESTASIS MULTIDOSERESTASISRETACRIT

RETEVMORETISERTREVATIOREVCOVIREVLIMIDREYVOWREZUROCKRIABNIRIBASPHERE RIBAPAK (1000 PACK)RIBASPHERE RIBAPAK (1200 PACK)RIBASPHERE RIBAPAK (600 PACK)RIBASPHERE RIBAPAK (800 PACK)RIBASPHEREribavirinRIBAVIRINRINVOQRISPERDAL CONSTAROMIDEPSINROZLYTREKRUBRACARUCONESTRUKOBIARUXIENCERUZURGIRYBELSUSRYBREVANTRYDAPTRYLAZESABRILsajazirSAMSCASANCUSOSANDOSTATIN LAR DEPOTSANDOSTATINSAPHNELOsapropterin dihydrochlorideSARCLISASAXENDASCENESSESECUADOSENSIPARSEROSTIMSEYSARASHELLGELSIGNIFOR LARSIGNIFORsildenafil citrateSILDENAFIL CITRATESINUVASIROLIMUSSIVEXTROSKYRIZI (150 MG DOSE)SKYRIZISODIUM IODIDE I-131sodium phenylbutyrateSODIUM PHENYLBUTYRATESOLESTASOLIRISsoloxideSOMATULINE DEPOTSOMAVERT

SPINRAZASPRAVATO (56 MG DOSE)SPRAVATO (84 MG DOSE)SPRYCELSTELARASTIVARGASTRENSIQSUBLOCADESUBSYSSUMADAN XLTSUNOSISUPPRELIN LASUSTOLSUTENTSYLATRONSYLVANTSYMDEKOSYMLINPEN 120SYMLINPEN 60SYMPROICSYNAGISSYNARELSYNDROSSYNRIBOTABRECTAtadalafil (pah)TAFINLARTAGRISSOTAKHZYROTALZENNATANZEUMTARCEVATARGRETINTASIGNATAVALISSETAZVERIKTECARTUSTECENTRIQTEGSEDITEMODARtemozolomidetemsirolimusTEPEZZATEPMETKOTESTIMTESTONE CIKTESTOPELTESTOSTERONE COMPOUNDINGKITTESTOSTERONE CYPIONATE &PROPTESTOSTERONE ENANTHATETESTOSTERONE PROPIONATETESTOSTERONETESTREDtetrabenazineTHALOMIDTHIOLA ECTHIOLATHYROGENTIBSOVO

(Continued)

The rights of the drug names appearing on this Prior Authorization Drug List, whether or not appearing in connection with the trademark symbol, belong exclusively to their owners.

©2021 WellDyne. All Rights Reserved

Page 4: 2021 Prior Authorization Drug List

2021 Prior Authorization Drug List

TOBI PODHALERTOBRAMYCINTOLSURATOLVAPTANTORISELTRACLEERTRAZIMERATRELSTAR MIXJECTTREMFYAtreprostinilTRIKAFTATRIPTODURTRODELVYTROGARZOTRULANCETRULICITYTRUSELTIQ (100MG DAILY DOSE)TRUSELTIQ (125MG DAILY DOSE)TRUSELTIQ (50MG DAILY DOSE)TRUSELTIQ (75MG DAILY DOSE)TRUXIMATUKYSATURALIOTYKERBTYMLOSTYSABRITYVASO REFILLTYVASO STARTERTYVASOUBRELVYUKONIQULTOMIRISUPLIZNAUPNEEQUPTRAVIVABOMEREVALCHLORVALTOCO 10 MG DOSEVALTOCO 15 MG DOSEVALTOCO 20 MG DOSEVALTOCO 5 MG DOSEVANTASVARUBI (180 MG DOSE)VARUBIVECTIBIXVELCADEVELETRIVEMLIDYVENCLEXTA STARTING PACKVENCLEXTAVENIPUNCTURE CPIVENTAVISVERQUVOVERZENIOVIBERZIVICTOZA

VIDAZAvigabatrinvigadroneVILTEPSOVIMIZIMVISTOGARDVISUDYNEVITRAKVIVIVITROLVIZIMPROVOGELXO PUMPVOGELXOVOSEVIVOTRIENTVPRIVVUMERITY (STARTER)VUMERITYVYEPTIVYLEESIVYNDAMAXVYNDAQELVYONDYS 53VYXEOSWAKIXWEGOVYWELIREGWINLEVIXADAGOXALKORIXATMEPXELJANZ XRXELJANZXEMBIFYXENICALXENLETAXEOMINXEPIXERAVAXERMELOXGEVAXIAFLEXXIFAXANXIIDRAXOFIGOXOLAIRXOSPATAXPOVIO (100 MG ONCE WEEKLY)XPOVIO (40 MG ONCE WEEKLY)XPOVIO (40 MG TWICE WEEKLY)XPOVIO (60 MG ONCE WEEKLY)XPOVIO (60 MG TWICE WEEKLY)XPOVIO (80 MG ONCE WEEKLY)XPOVIO (80 MG TWICE WEEKLY)XTANDIXULTOPHYXURIDEN

XYOSTEDXYREMXYWAVYERVOYYESCARTAYONDELISYONSAYUTIQZALTRAPZARXIOZAVESCAZEJULAZELBORAFZELNORMZEMAIRAZEMDRIzenataneZENEVIXZENZEDIZEPOSIA 7-DAY STARTER PACKZEPOSIA STARTER KITZEPOSIAZEPZELCAZIEXTENZOZINBRYTAZINPLAVAziprasidone mesylateZIRABEVZOKINVYZOLADEXZOLEDRONIC ACIDZOLINZAZOMETAZORBTIVEZULRESSOZYDELIGZYKADIAZYNLONTAZYPREXA RELPREVV

Bolded products represent drugs requiring prior authorization for medical necessity that are new for the 2018 plan year

There may be additional drugs subject to prior authorization or other plan design restrictions. Please consult your plan for further information. Products covered bya member’s prescription benefit plan may change from time to time. Preferred brand products are listed in UPPERCASE LETTERS, generic products are listed inlower-cased italics, and other products listed are non-preferred. Medications are covered based on member’s benefit plan design, regardless of their appearance onthis document. The listed formulary items are subject to change.

The rights of the drug names appearing on this Prior Authorization Drug List, whether or not appearing in connection with the trademark symbol, belong exclusively to their owners.

©2021 WellDyne. All Rights Reserved


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