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Pharmacy Prior Authorization and Step Therapy

Drugs selected for Prior Authorization (PA) 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
Adcirca
Advicor
Afinitor
Altoprev
Ampyra
Aplenzin
Aranesp
Arcalyst
Aubagio
Avonex
Axiron
Betaseron
Bio-T-Gel
Bosulif
Bravelle
Brintellix
Caduet
Caprelsa
Caverject
Celebrex
Celexa
Cetrotide
Chantix
Chorionic-
    gonadotropin 
Cialis
Cimzia
Clomid
clomiphene
Cometriq
Copaxone
Crestor
Crinone Gel
Cymbalta
Desvenlafaxine   Dexilant
Edex
Effexor (XR)
Egrifta
Enbrel
Endometrin

         Epogen
Erivedge
Extavia
Fentanyl oral
Fentora
First-lansoprazole-  
    suspension kit
First-omeprazole-
    suspension kit
First-Testosterone
   (MC)
fluoxetine 60mg tabs
Follistim AQ
Forfivo XL
Fortesta
Ganirelix acetate
Genotropin
Gilenya
Gilotrif
Gleevec
Gonal-F
Hexalen
Humatrope
Humira
Hycamtin
Iclusig
Ilaris
Incivek
Inlyta
Jakafi
Kineret
Kuvan
Lazanda
Lescol (XL)
Levitra
Lexapro
Lipitor
Liptruzet
Livalo
Lunesta
Luveris
Luvox CR
Lysodren
Maprotiline
          Matulane
Mekinist
Menopur
Mevacor
Modafanil
Muse
Nexavar
Nexium
Norditropin
Novarel
Noxafil
Nutropin (AQ)
Nuvigil
Oforta
Oleptro
Olysio
Omnitrope
Omontys
Onsolis
Orencia self-injectable
Ovidrel
Paxil (CR)
Pegasys
PegIntron
Pexeva
Pomalyst
Pravachol
Pregnyl
Prevacid
Prilosec
Pristiq
Procrit
Progesterone
Protonix
Provigil
Prozac (Weekly)
Rebif
Remeron (SolTab)
Repronex
Revatio
Revlimid
Saizen
Serophene
Serostim
         Simcor
Simponi
Solvadi
Sprycel
Staxyn
Stelara
Stivarga
Striant
Subsys
Sutent
Sylatron
Tafinlar
Tarceva
Targretin
Tasigna
Tecfidera
Temodar
Testim
Tev-Tropin
Thalomid
tretinoin (oral)
Tykerb
Vandetanib
Venlafexine ER
Vfend
Viagra
Victrelis
Viibryd
Voriconazole
Votrient
Vytorin
Wellbutrin (SR)(XL)
Xalkori
Xeljanz
Xeloda
Xtandi
Zegerid
Zelboraf
Zocor
Zolinza
Zoloft
Zorbitive
Zyban
Zytiga

Specific fax forms are required for most of the drugs listed above.  Click on the link below to go to the Forms Page on our website.
 Download  Prior Authorization Physician Fax Forms

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


 
                                                                                

 
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Pharmacy Prior Authorization