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Content with Policies & Guidelines Draft Self-Administered Drug Policies .

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print Print Back Back Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary Policy...

Filsuvez

Androderm, AndroGel, Fortesta, Natesto, Striant, Testim, testosterone solution, Vogelxo, Jatenzo, Methitest, methyltestosterone capsule, Tlando, Anadrol-50, danazol, Oxandrin, Kyzatrex

Abrilada, Actemra, Amjevita, Bimzelx, Cimzia, Cosentyx, Cyltezo, Enbrel, Entyvio, Hadlima, Hulio, Humira, Hyrimoz/Adalimumab-adaz, Idacio, Kevzara, Kineret, Litfulo, Olumiant, Omvoh, Orencia,...

See Policy for list of drugs

Adlyxin, Byetta, Bydureon, Bydureon BCise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza

Pegasys, PegIntron

Otezla

Eliquis, Pradaxa, Savaysa, Xarelto

Abilify, Abilify Mycite, Caplyta, Clozapine ODT, Clozaril, Fanapt, FazaClo, Geodon, Invega ER, Latuda, Lybalvi, Rexulti, Risperdal, Risperdal M-Tab, Risperidone ODT, Saphris, Secuado, Seroquel,...

Aimovig, Ajovy, Emgality, Nurtec ODT, Ubrelvy, Qulipta, Ubrelvy, Zavzpret

Hetlioz, Hetlioz LQ

 

Emflaza

Gralise, Horizant

See Policy for Available Brands

Juxtapid

Ambien, Ambien CR, Belsomra, Dayvigo, Edluar,  Lunesta, Quviviq, Rozerem, Silenor, Zolpimist

Arcalyst

Lyrica, Savella