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Pharmacy Prior Authorization and Step Therapy

Physicians can access, complete and submit Prior Authorization and Step Therapy request forms electronically from the CoverMyMeds® website:

For more information on CoverMyMeds®, click here.

Drugs selected for Prior Authorization may require that specific clinical criteria are met before the drugs will be covered under a member’s prescription benefit. The following drugs, and generic versions if available, are subject to PA.

Step Therapy
programs are designed to help members use the lowest cost product(s) within a drug class.   Drugs subject to step therapy are widely considered equivalent to other products within the class by both physicians and pharmacists.   In order to obtain a medication within a step therapy program, the member must fail a first line drug.   In general, first line products are usually generic medications.   In some cases, medical policy will allow the step therapy to be waived.   Refer to the pharmacy policy for specific exceptions.

This list is subject to change and may not be applicable to all benefit plans.  Refer to your member contract for clarification.  This list includes drugs that process off of the pharmacy benefit. 

Abstral
Aciphex
Actiq
Actemra
Acticlate
Adcirca
Adempas
Adoxa
Adoxy DK
Advicor
Afinitor
Altoprev
Amevive
Ampyra
Androderm
AndroGel
Android
Androl-50
Androxy
Apidra
Aplenzin
Aranesp
Arcalyst
Aubagio
Aveed
Avidoxy DK
Avonex
Axiron
Betaseron
Bio-T-Gel
Bosulif
Bravelle
Brintellix
Bunavail
Buphenyl
Byetta
Bydureon
Caprelsa
Caverject
Celebrex
Celexa
Cetrotide
Chorionic-
    gonadotropin 
Cialis
Cimzia
Clomid
clomiphene
Cometriq
Copaxone
Crestor
Crinone Gel
Cymbalta
Danazol
Delatestryl
Depo-Testosterone
Desvenlafaxine
Dexilant
Doryx
Doxycycline
Duexis
Dynacin
Edex



         Effexor (XR)
Egrifta
Enbrel
Endrometri
Entyvio
Epogen
Erivedge
Esomeprazole strontium
Extavia
Fentanyl oral
Fentora
Ferriprox
Fetzima
First-lansoprazole-  
    suspension kit
First-omeprazole-
    suspension kit
First-Testosterone
   (MC)
fluoxetine 60mg tabs
Follistim AQ
Forfivo XL
Forteo
Fortesta
Ganirelix acetate
Gattex
Genotropin
Gilenya
Gilotrif
Gleevec
Glucose Test strips-
     non-preferred
Gonal-F
Harvoni
Hexalen
H.P. Acthar Gel
Humatrope
Humira
Humulin
Humalog
Hycamtin
Iclusig
Ilaris
Imbruvica
Incivek
Infergen
Inlyta
Jakafi
Juxtapid
Kalydeco
Khedezla
Kineret
Kuvan
Kynamro
Lazanda
Lescol (XL)
Letairis
Levitra
Lexapro
Lipitor
Liptruzet
Livalo
Luvox CR
          Lysodren
Maprotiline
Matulane
Mekinist
Menopur
Methitest
Mevacor
Minocin (Kit)
Modafanil
Monodox
Morgidox Kit
Muse
Nexavar
Nexium
Nicazeldoxy Kit
Norditropin (AQ)
Novarel
Noxafil
Nplate
Nutridox Kit
Nutropin (AQ)
Nuvigil
Ocudox Kit
Oforta
Oleptro
Olysio
Omnitrope
Omontys
Onsolis
Opsumit
Oracea
Oraxyl
Orencia self-injectable
Orenitram
Otezla
Oxandrin
Ovidrel
Paxil (CR)
Pegasys
PegIntron
Pexeva
Pomalyst
Pravachol
Pregnyl
Prevacid
Prilosec
Pristiq
Procrit
Progesterone
Promacta
Protonix
Provigil
Prozac (Weekly)
Ravicti
Rebif
Remeron (SolTab)
Repronex
Revatio
Revlimid
Rituxan
Saizen
Serostim
Signifor
         Simcor
Simponi Aria
Solodyn
Solvadi
Sprycel
Staxyn
Stelara
Stendra
Stivarga
Striant
Suboxone
Subsys
Sutent
Sylatron
Tafinlar
Tanzeum
Tarceva
Targretin
Tasigna
Tecfidera
Temodar
Testim
Testosterone
Testopel
Testred
Tev-Tropin
Thalomid
Tracleer
tretinoin (oral)
Tykerb
Venlafexine ER
Vfend
Viagra
Vibramycin
Victoza
Victrelis
Viibryd
Vimovo
Vogelxo
Voriconazole
Votrient
Vytorin
Wellbutrin (SR)(XL)
Xalkori
Xeljanz
Xeloda
Xenazine
Xtandi
Xyrem
Zegerid
Zelboraf
Zocor
Zolinza
Zoloft
Zorbitive
Zubsolv
Zydelig
Zykadia
Zytiga

The Pharmacy Policy page contains Pharmacy Policies for each medication above.  Click on 
Pharmacy Policy and PA Forms page to view policies.  Prior Authorization fax forms are also available on this link.


 
                                                                                

 
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Pharmacy Prior Authorization