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Prior-Authorization

The following list of Drugs require a Prior Authorization (PA).

Therapy ClassDrug Name
NarcolepsyProvigil, Nuvigil
Erectile DysfunctionCialis, Viagra, Levitra, Muse, Caverject, Edex
Oral AcneAccutane, Amnesteem, Claravis, Sotret
Topical AcneDifferin, Retin-A, Tazorac, Avita, Atralin, Tretinoin, Tretin-X, Ziana
AnemiaEpogen, Aranesp, Procrit
Arthritis/ PsoriasisHumira, Enbrel, Kineret, Remicade, Orencia, Celebrex, Simponi, Stelara, Xeljanz
AsthmaXolair
Growth HormoneGenotropin, Humatrope, Geref, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Tev-Tropin, Zorbtive, Increlex, Iplex, Serostim
Multiple SclerosisAmpyra, Aubagio, Gilenya, Tecfidera, Tysabri
OsteoporosisForteo
Hepatitis CIncivek, Intron A, Victrelis, Sovaldi, Olysio
ADHDVyvanse, Daytrana
Crohn's DiseaseCimzia
Miscellaneous AgentsActhar Gel, Afinitor, Brilinta, Daliresp, Effient, Elelyso, Firazyr Fulyzaq, Kalydeco, Krystexxa,Kynamro Juxtapid Lazanda, Makena, Nplate, Samsca, Supprelin LA, Synagis, Vivitrol, Xenazine
Botulinum Toxin ProductsBotox, Dysport, Myobloc, Xeomin
DiabetesByetta, Bydureon, Victoza
Testosterone ReplacementAndrogel, Androderm, Axiron, Fortesta, Striant, Testim
Chemotherapy AgentsBosulif, Synribo

* Codes J9035 (Avastin), J1745 (Remicade) and J9010 (Rituxan) require pre-authorization. To expedite treatment and claims processing for indications included in FDA labeling or national guidelines, select ICD-9 diagnoses will be exempt from the prior authorization requirement. View a list of these diagnoses.

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