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Medication Policies

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View associated prior authorization forms.

View recent prior authorization changes.

IMPORTANT REMINDER

Medication Policies have been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medication policy is to provide a guide to coverage. Medication Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   V   W   X   Y   Z

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Medication Name
Medication Policy
Position Summary
A
Aciphex®, rabeprazoe
Aciphex®, rabeprazoe (Medicare Part D Members Only)
Actiq®, fentanyl citrate oral transmucosal lozenges
ACTOplus met™, pioglitazone-metformin
Actos®, pioglitazone
Actos®, pioglitazone-Containing Medications (Actos®, ACTOplus Met™, Duetact™)
Altinac®, tretinoin topical
Ambien®, zolpidem
Ambien CR™, zolpidem MR
Amerge®, naratriptan
Amevive®, alefacept
Antineoplaston Cancer Therapy
Anzemet®, dolasetron
Aranesp®, darbepoetin
Avandamet®, rosiglitizone/metformin
Avandia®, rosiglitazone
AvandarylTM, rosiglitazone/glimepiride
Avandia®, rosiglitazone-Containing Medications (Avandia®, Avandamet®, AvandarylTM)
Avita®, tretinoin topical
Axert®, almotriptan
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B
Baygaym®, (Immune Globulin Replacement Therapy)
Betaseron®, interferon beta-1b
Botox®, botulinum toxin Type A Injection
Byetta®, exenatide
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C
Carimune NF (Immune Globulin Replacement Therapy)
Celebrex®, celecoxib
Cerezyme®, imglucerase
Chelation Therapy
Cialis®, tadalafil
Cialis®, tadalafil (Medicare Part D Only)
Compounded Medications
Crestor®, rosuvastatin
Cymbalta®, duloxetine
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D
Duetact™, pioglitazone-glimepiride
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E
Effexor XR®, venlafaxine extended-release capsulses
Emend®, aprepitant
Enbrel®, etanercept
Epogen®, erythropoietin
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F
Fentora®, fentanyl citrate buccal tablet
Flebogamma®
Forteo®, teriparatide
Frova®, frovatriptan
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G
Gamastan®, (Immune Globulin Replacement Therapy)
Gammagard S/D®, (Immune Globulin Replacement Therapy)
Gammimune N®, (IVIG, Intravenous Immunoglobulins)
Gamunex®, (Immune Globulin Replacement Therapy)
Genotropin®, somatropin
Gleevec®, imatinib mesylate
Growth Hormone (GH)
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H
Humatrope®, somatropin
Humira®, adalimumab
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I
Increlex®, mecasermin
Imitrex®, sumatriptan
Infergen® interferon alfocan-1
Iveegam®, (Immune Globulin Replacement Therapy)
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J
Januvia™, sitagliption
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K
Kineret®, anakinra
Kuvan®, sapropterin dihydrochloride
Kytril®, granisetron
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L
Lamisil®, terbinafine oral
Levitra®, vardenafil
Levitra®, vardenafil (Medicare Part D Only)
Levonorgestrel-containing Intrauterine System (LNG-IUS) for Medical Conditions
Lexapro®, escitalopram
Lipitor®, atorvastatin
Lunesta®
Luvox® CR, fluvoxamine extended-release capsules
Lyrica®, pregabalin
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M
Maxalt®, rizatriptan
Mirena®, Levonorgestrel-containing Intrauterine System (LNG-IUS) for Medical Conditions
MyoBloc®, botulinum toxin Type B
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N
Nexavar®, sorafenib
Nexium®, esomeprazole
Non-Formulary Medications, Medical Exception Criteria for Closed Pharmacy Benefit Designs
Non-preferred Medications, Medical Exception Criteria for Tiered Benefit Designs with Tier Copay Exceptions
Non-Formulary Medications, Medical Exception Criteria for Closed Pharmacy Benefit Designs
Norditropin®, somatropin
Nutropin®, somatropin
Nutropin AQ®, somatropin
Nutropin Depot®, somatropin
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O
Octagam® (Immune Globulin Replacement Therapy)
Off-Label Drug Use of FDA Approved Drugs
Opana® ER, oxymorphone, Extended Release
Opioids for Chronic Noncancer Pain
Oral Contraceptives for Medical Conditions
Orencia®, abatacept
OxyContin®, oxycodone CR
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P
Paxil CR®, paroxetine CR
Pegasys®, peginterferon alfa-2a
PEG-Intron®, peginterferon alfa-2b
Penlac®, ciclopirox
Polygam S/D®, (Immune Globulin Replacement Therapy)
Prevacid®, lansoprazole
Pristiq™, desvenlafaxine
Privigen®, Immune Globulin Replacement Therapy
Procrit®, erythropoietin
Protonix®, pantoprazole
Provigil®, modafinil
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R
Raptiva®, efalizumab
Relenza®, zanamivir
Relpax®, eletriptan
Remicade®, infliximab
Renova®, tretinoin topical
Retin A®, tretinoin topical
Retin A Micro®, tretinoin topical
Revatio™, sildenafil 20mg
Revlimid®, lenalidomide
Rozerem®, ramerteon
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S
Saizen®, somatropin
Self-Adminsitered Injectables
Serostim®, somatropin
Solage®, tretinoin topical
Sonata®, zaleplon
Sporanox®, itraconazole oral
Sprycel®, dasatinib
Stadol NS®, butorphanol tartrate nasal spray
Sutent®, sunitinib
Symlin®, pramlinitide
Synagis®, respiratory syncytial virus prophylaxis
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T
Tamiflu®, oseltamivir
Tarceva®, erlotinib
Tasigna®, nilotinib
Tev-Tropin®, somatropin
Tykerb®, lapatinib
Tysabri®, natalizumab
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V
Venoglobulin®, (IVIG, Intravenous Immunoglobulins)
Viagra®, sildenafil
Viagra®, sildenafil (Medicare Part D Only)
Vivaglobin®, subcutaneous immunoglobulin (Immune Globulin Replacement Therapy)
Vytorin®, simvastatin/ezetimibe
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X
Xolair®, omalizumab
Xyrem®, sodium oxybate
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Z
Zavesca®, miglustat
Zegerid®, omeprazole
Zofran®, ondansetron
Zolinza™, vorinostat
Zomig®, zolmitriptan
Zorbtive®, somatropin
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