MANAGED MEDICAID AUTHORIZATION LIST The following prescription drugs require PRIOR AUTHORIZATION Certain medications require prior authorization, which means approval is needed before the prescriptioncan be filled. If approval is not received, the drug may not be covered. abiraterone acetate ABSORICA ABSTRAL ACANYA ACIPHEX SPRINKLE ACTEMRA ACTICLATE ACTIMMUNE ACTIQ adapalene ADCIRCA ADEMPAS ADZENYS ER ADZENYS XR-ODT AFINITOR AIMOVIG AUTOINJECTOR AJOVY ALECENSA ALUNBRIG amlodipine-valsartan amlodipine-valsartan-hctz AMPYRA AMRIX ANDRODERM ANDROGEL ANDROID ANDROXY ANODYNE LPT APTIOM ARCALYST ARIKAYCE ARYMO ER ASTAGRAF XL AUSTEDO AUVI-Q AVITA AXIRON BENLYSTA BERINERT bexarotene BONJESTA BOSULIF BRAFTOVI BRIVIACT budesonide er buprenorphine patch BUTRANS CABOMETYX CALQUENCE CAPRELSA CARAC CARBAGLU carisoprodol 250mg CENTANY AT CERDELGA chlorzoxazone 250mg CHOLBAM CIMZIA CINRYZE CLINDACIN ETZ CLINDACIN PAC clindamycin phos-benzoyl perox clindamycin phos-tretinoin CLODAN COMETRIQ COMFORT PAC-CYCLOBENZAPRINE COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN COMFORT PAC-TIZANIDINE COPEGUS COPIKTRA COSENTYX COTELLIC COTEMPLA XR-ODT CUPRIMINE CUVPOSA cyclobenzaprine hcl 7.5mg cyproheptadine hcl syrup CYSTARAN PAGE 1
DAKLINZA dalfampridine er DAURISMO DERMACINRX CINLONE-I CPI DERMACINRX CLORHEXACIN DERMACINRX EMPRICAINE DERMACINRX LEXITRAL DERMACINRX PRIZOPAK DERMACINRX SILAPAK DERMACINRX SILAZONE DERMACINRX SURGICAL PHARMAPAK DERMACINRX THERAZOLE PAK DERMAZONE dexamethasone therapy pack DICLEGIS DICLO GEL DICLO GEL-XRYLIX SHEET diclofenac sodium 3% DICLOPR DICLOTRAL DICLOZOR DITHOL DOLOTRANZ DOPTELET doxycycline hyclate DUEXIS DUPIXENT DURAGESIC DUZALLO DYANAVEL XR DYMISTA EGRIFTA ELLZIA PAK EMBEDA EMFLAZA EMGALITY EMVERM ENBREL ENBREL MINI ENBREL SURECLICK ENDARI ENSTILAR ENVARSUS XR EPANDED SOLUTION EPCLUSA EPIDIOLEX ERIVEDGE ERLEADA ESBRIET ESOMEP-EZS esomeprazole strontium EXALGO EXTAVIA ENTERAL FORMULA REQUIRES PRIOR AUTHORIZATION. FABIOR FARYDAK fenoprofen calcium FENORTHO fentanyl patch fentanyl citrate FENTORA FEXMID FIRAZYR FLECTOR FLEXIPAK fluorouracil 0.5% cream FORTEO FORTESTA FULYZAQ GALAFOLD GATTEX GENOTROPIN GIAZO GILOTRIF GLYCATE glycopyrrolate 1.5mg GOCOVRI GONITRO GRALISE GRANIX H.P. ACTHAR HAEGARDA PAGE 2
HARVONI HETLIOZ HORIZANT HUMATROPE HYCAMTIN hydromorphone er HYSINGLA ER HUMIRA IBRANCE ICLUSIG IDHIFA IMBRUVICA IMPAVIDO INCRELEX INFLAMMACIN INGREZZA INLYTA IRESSA JAKAFI JUBLIA JUXTAPID JYNARQUE KADIAN KALYDECO KERYDIN KEVEYIS KEVZARA KINERET KISQALI KISQALI FEMARA CO-PACK KORLYM KRISTALOSE KUVAN KYNAMRO lactulose packet LAMISIL GRANULES LAZANDA ledipasvir-sofosbuvir LENVIMA LETAIRIS levorphanol tartrate LEXIXRYL LIDO-PRILO CAINE PACK LIDOPAC LIDOPRIL LIDOPRIL XR LIDOTRANS 5 PAK LIPROZONEPAK LONSURF LOPROX LORBRENA LORZONE LYNPARZA LYRICA CR MAVYRET MEDOLOR PAK MEKINIST MEKTOVI mesalamine kit methadone hcl METHADONE INTENSOL METHADOSE METHITEST methyltestosterone miglustat minocycline hcl er MINOLIRA ER MODERIBA MORGIDOX MORPHABOND ER morphine sulfate er MOXATAG MOZOBIL MULPLETA MYALEPT MYTESI NALFON NAMZARIC NATESTO NATPARA NERLYNX PAGE 3
NEUPOGEN NEUPRO NEURCAINE NEXAVAR NINLARO nitroglycerin spray NITYR NIVESTYM NORDITROPIN FLEXPRO NORTHERA nortriptyline dose cup NUCYNTA ER NUDICLO NUDROXIPAK NUDROXIPAK DSDR-50 NUDROXIPAK DSDR-75 NUDROXIPAK E-400 NUDROXIPAK I-800 NUDROXIPAK N-500 NUEDEXTA NUPLAZID NUTRESTORE NUTRIARX NUTROPIN AQ OCALIVA ODOMZO OFEV OLUMIANT OLYSIO OMECLAMOX-PAK OMNITROPE ONEXTON ONMEL OPSUMIT ORAVIG ORENCIA ORENITRAM ER ORFADIN ORILISSA ORKAMBI OSMOLEX ER OTEZLA OTREXUP OXERVATE OXTELLAR XR oxycodone hcl er OXYCONTIN oxymorphone hcl er PAINGO KFT PALYNZIQ paroxetine mesylate 7.5mg PEDIADERM HC PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PENNSAID POMALYST PRALUENT PREVIDOLRX PLUS ANALGESIC PAK PRILOLID PROCYSBI PROFENO PROMACTA PURIXAN QBRELIS QUALAQUIN QUDEXY XR QUILLICHEW ER QUILLIVANT XR quinine sulfate RASUVO RAVICTI RAYOS REBETOL RELADOR PAK REPATHA REVATIO REVLIMID RIBASPHERE RIBASPHERE RIBAPAK RIBATAB PAGE 4
ribavirin ROSADAN ROWASA RUBRACA RUCONEST RYDAPT RYTARY SABRIL SAIZEN SANADERMRX SEROSTIM SIGNIFOR SIKLOS SILALITE PAK SILAZONE-II sildenafil 20mg SILIQ SIMPONI SITAVIG SIVEXTRO sofosbuvir-velpatasvir SOLARAZE SOLODYN SOLTAMOX SOLUPAK SOMA SOMAVERT SORILUX SOTYLIZE SOVALDI SPRITAM SPRIX SPRYCEL STELARA STIVARGA STRENSIQ STRIANT SUBSYS SUCRAID SUTENT SYLATRON SYMDEKO SYNALAR TS SYNDROS SYPRINE TACLONEX SUSP tadalafil 20mg TAFINLAR TAGRISSO TAKHZYRO TALZENNA TAPERDEX TARCEVA TARGRETIN TASIGNA TAVALISSE TECHNIVIE TEGSEDI TESTIM testosterone - topical TESTRED tetrabenazine TIBSOVO TICALAST TICANASE TICASPRAY TIVORBEX topiramate er TRACLEER tramadol er caps tramadol hcl er TREMFYA TRETIN-X tretinoin cream 0.05% tretinoin microsphere TRI-SILA trientine hcl PAGE 5
TRIXYLITRAL TROKENDI XR TYKERB TYMLOS TALTZ TYVASO UCERIS ULTRAVATE X UPTRAVI VACUSTIM BLACK VACUSTIM SILVER VALCHLOR VELTIN VENCLEXTA VERZENIO VIEKIRA PAK VIEKIRA XR vigabatrin VIMOVO VITRAKVI VIVLODEX VIZIMPRO VOGELXO VOSEVI VOTRIENT WHYTEDERM TRILASIL PAK XALKORI XARTEMIS XR XATMEP XELITRAL XELJANZ XELJANZ XR XENAFLAMM XERESE XERMELO XHANCE XIMINO XOSPATA XRYLIX XTAMPZA ER XTANDI XURIDEN XYOSTED XYREM YONSA ZEJULA ZELAPAR ZELBORAF ZEPATIER ZEYOCAINE ZIANA ZIPSOR ZODEX ZOHYDRO ER ZOLINZA ZOMACTON ZONTIVITY ZORBTIVE ZORVOLEX ZURAMPIC ZYDELIG ZYKADIA ZYTIGA PAGE 6
MANAGED MEDICAID STEP THERAPY LIST The following prescription drugs require STEP THERAPY Step Therapy requires that members try certain First Line options before other medications will be considered medically necessary for treatment of a specific condition. Step therapy requirements may apply to both brand and generics. Typically First Line medications are classified as generics, but there are instances where brand name medications may be preferred. ALOGLIPTIN BENZOATE ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL ALTABAX AMITIZA APLENZIN AUBAGIO BETASERON BIMATOPROST 0.03 % DROPS BYDUREON BYDUREON BCISE BYDUREON PEN BYETTA BYSTOLIC CAMBIA CIMZIA CLOCORTOLONE PIVALATE 0.1 %CREAM(G) CLODERM COSENTYX DAKLINZA DESONATE DESVENLAFAXINE FUMARATE DIFICID DURAGESIC EDLUAR EMSAM ENTRESTO EPCLUSA FANAPT FOSAMAX PLUS D GENOTROPIN HALOG HARVONI HUMATROPE INVOKAMET INVOKAMET XR INVOKANA KADIAN KEVZARA KHEDEZLA KINERET LATUDA PAGE 1 LEVALBUTEROL TARTRATE HFA LUMIGAN LYRICA MORPHINE SULFATE NORDITROPIN FLEXPRO NUTROPIN AQ OLEPTRO ER OLYSIO ORENCIA PANDEL PEXEVA RAPAFLO REXULTI ROZEREM SAIZEN SANCUSO SAPHRIS SAVELLA SEGLUROMET SILENOR SILIQ SIMPONI STEGLATRO TECHNIVIE TREMFYA TRIANEX TUZISTRA XR TALTZ ULORIC VERDESO VICTOZA 2-PAK VICTOZA 3-PAK VIEKIRA PAK VIEKIRA XR XOPENEX HFA ZEPATIER ZINBRYTA ZOLPIMIST Please submit completed PA and Step Therapy forms to: Pharmacy Help Desk Mail to: 165 Court Street, Rochester, NY 14647 Fax: 1 (800) 956-2397 Phone: 1 (800) 499-1275