prior authorization drug list

Prior Authorization Drug List

Drug Class Drugs Requiring Prior Authorization

ADAMANTANES (CNS)OSMOLEX ER

ADRENALSbudesonide er EMFLAZA

ADRENOCORTICAL INSUFFICIENCYACTHAR

ALLERGENIC EXTRACTS (THERAPEUTIC)GRASTEK ODACTRA

ORALAIR PALFORZIA

RAGWITEK

ALPHA- AND BETA-ADRENERGIC AGONISTSdroxidopa EPIPEN

EPIPEN 2-PAK NORTHERA

ALPHA-ADRENERGIC AGONISTSLUCEMYRA

AMINOGLYCOSIDE ANTIBIOTICSARIKAYCE BETHKIS

KITABIS PAK TOBI

TOBI PODHALER tobramycin

AMINOMETHYLCYCLINESNUZYRA SEYSARA

CAPITAL LETTERS = BRAND MEDICATIONSlower case = generic medicationsThis list is subject to change and does not define coverage.Only your plan can determine coverage of your benefit.

Pg 1_Prior Authorization_MAGELLAN Rx PRECISION FORMULARY_10/2021


AMMONIA DETOXICANTS

AMPHETAMINE DERIVATIVESdiethylpropion hcl diethylpropion hcl er

LOMAIRA phendimetrazine tartrate

phendimetrazine tartrate er phentermine hcl

AMPHETAMINESbenzphetamine hcl

AMYLINOMIMETICSSYMLINPEN 120 SYMLINPEN 60

ANALGESICS AND ANTIPYRETICS, MISC.LYRICA CR pregabalin er

ANDROGENSANDRODERM ANDROID

METHITEST OXANDRIN

oxandrolone STRIANT

TESTRED

ANOREXIGENIC AGENTS, MISCELLANEOUSIMCIVREE QSYMIA

ANTHELMINTICSalbendazole ALBENZA

BILTRICIDE EMVERM

ivermectin praziquantel

STROMECTOL

ANTI-INFLAMMATORY AGENTS (GI DRUGS)LOTRONEX

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)ALTABAX CENTANY

XEPI ZILXI




ANTICONVULSANTS, MISCELLANEOUSAPTIOM BANZEL

BRIVIACT DIACOMIT

EPIDIOLEX FELBATOL

FINTEPLA HORIZANT

rufinamide SABRIL

vigabatrin VIGADRONE

XCOPRI

ANTIDEPRESSANTS, MISCELLANEOUSSPRAVATO

ANTIDIABETIC AGENTS, MISCELLANEOUSKORLYM

ANTIDIARRHEA AGENTSXERMELO

ANTIEMETICS, MISCELLANEOUSMARINOL SYNDROS

ANTIFIBROTIC AGENTSESBRIET OFEV

ANTIGONADTROPINSCETROTIDE ganirelix acetate

ORGOVYX ORIAHNN

ORILISSA

ANTIHISTAMINES (GI DRUGS)BONJESTA DICLEGIS

doxylamine succ-pyridoxine hcl

ANTILIPEMIC AGENTS, MISCELLANEOUSicosapent ethyl JUXTAPID

NEXLETOL NEXLIZET



VASCEPA


ANTIMALARIALSatovaquone-proguanil hcl MALARONE

QUALAQUIN quinine sulfate

ANTIMUSCARINICS/ANTISPASMODICSLONHALA MAGNAIR REFILL LONHALA MAGNAIR STARTER

QBREXZA

ANTINEOPLASTIC AGENTSAFINITOR AFINITOR DISPERZ

ALECENSA ALUNBRIG

AVASTIN AYVAKIT

BALVERSA bexarotene

BOSULIF BRAFTOVI

BRUKINSA CABOMETYX

CALQUENCE capecitabine

CAPRELSA CARAC

COMETRIQ COPIKTRA

COTELLIC cyclophosphamide

DAURISMO diclofenac sodium

ERIVEDGE ERLEADA

erlotinib hcl everolimus

FARYDAK FEMARA

FOTIVDA GAVRETO

GILOTRIF GLEEVEC

HERCEPTIN HERCEPTIN HYLECTA

HYCAMTIN IBRANCE

ICLUSIG IDHIFA

imatinib mesylate IMBRUVICA

INLYTA INQOVI

INREBIC IRESSA




ANTINEOPLASTIC AGENTS -- ContinuedJAKAFI KANJINTI

KISQALI KISQALI FEMARA CO-PACK

KOSELUGO lapatinib

LENVIMA LONSURF

LORBRENA LUMAKRAS

LYNPARZA MEKINIST

MEKTOVI MVASI

NERLYNX NEXAVAR

NINLARO NUBEQA

ODOMZO OGIVRI

ONUREG OTREXUP

PEMAZYRE PIQRAY

POMALYST PURIXAN

QINLOCK RASUVO

RETEVMO REVLIMID

RITUXAN RITUXAN HYCELA

ROZLYTREK RUBRACA

RUXIENCE RYDAPT

SOLARAZE SPRYCEL

STIVARGA SUTENT

SYNRIBO TABRECTA

TAFINLAR TAGRISSO

TALZENNA TARCEVA

TARGRETIN TASIGNA

TAZVERIK TEMODAR

temozolomide TEPMETKO

TIBSOVO TRAZIMERA

TRUSELTIQ TUKYSA

TURALIO TYKERB

UKONIQ VALCHLOR




ANTINEOPLASTIC AGENTS -- ContinuedVENCLEXTA STARTING PACK VERZENIO

VITRAKVI VIZIMPRO

VOTRIENT XALKORI

XATMEP XELODA

XOSPATA XPOVIO

XTANDI YONSA

ZEJULA ZELBORAF

ZIRABEV ZOLINZA

ZYDELIG ZYKADIA

ZYTIGA

ANTIPARATHYROID AGENTScinacalcet hcl

ANTIPROTOZOALS, MISCELLANEOUSALINIA atovaquone

LAMPIT MEPRON

nitazoxanide

ANTIPRURITICS AND LOCAL ANESTHETICSPRUDOXIN ZONALON

ANTISENSE OLIGONUCLEOTIDESTEGSEDI

ANTITOXINS AND IMMUNE GLOBULINSBIVIGAM CUTAQUIG

CUVITRU FLEBOGAMMA DIF

GAMMAGARD LIQUID GAMMAKED

GAMMAPLEX GAMUNEX-C

HIZENTRA HYQVIA

HYQVIA IG COMPONENT OCTAGAM

PRIVIGEN XEMBIFY




ANTITUBERCULOSIS AGENTSSIRTURO

ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)acyclovir DENAVIR

XERESE

ANTIVIRALS, MISCELLANEOUSPREVYMIS

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISCHETLIOZ HETLIOZ LQ

ATYPICAL ANTIPSYCHOTICSABILIFY MAINTENA ABILIFY MYCITE

ARISTADA ARISTADA INITIO

CAPLYTA INVEGA SUSTENNA

INVEGA TRINZA NUPLAZID

PERSERIS REXULTI

RISPERDAL CONSTA ZYPREXA RELPREVV

AZOLE ANTIFUNGALSCRESEMBA ONMEL

AZOLES (SKIN AND MUCOUS MEMBRANE)luliconazole

BENZODIAZEPINES (ANTICONVULSANTS)clobazam

BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.OXBRYTA TAVALISSE

BONE RESORPTION INHIBITORSPROLIA XGEVA

CALCITONIN GENE-RELATED PEPTIDE ANTAG.AIMOVIG AUTOINJECTOR EMGALITY PEN

EMGALITY SYRINGE NURTEC ODT




CALCITONIN GENE-RELATED PEPTIDE ANTAG. -- Continued

CALORIC AGENTSDOJOLVI

CARBONIC ANHYDRASE INHIBITORS (MISC.)KEVEYIS

CARDIAC DRUGS, MISCELLANEOUSCORLANOR VYNDAMAX

VYNDAQEL

CELL STIMULANTS AND PROLIFERANTSALTRENO ATRALIN

TRETIN-X tretinoin microsphere

CENTRAL NERVOUS SYSTEM AGENTS, MISC.ADDYI EXSERVAN

NOURIANZ NUEDEXTA

TIGLUTIK VYLEESI

XYREM XYWAV

CLASS III ANTIARRHYTHMICSMULTAQ

COMPLEMENT INHIBITORSBERINERT CINRYZE

EMPAVELI FIRAZYR

HAEGARDA icatibant

KALBITOR ORLADEYO

RUCONEST SOLIRIS

TAKHZYRO

CORTICOSTEROIDS (EENT)EYSUVIS

CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)BRYHALI halcinonide




CYSTIC FIBROSIS (CFTR) CORRECTORSTRIKAFTA

CYSTIC FIBROSIS (CFTR) POTENTIATORSKALYDECO ORKAMBI

DEVICESDUROLANE EUFLEXXA

GEL-ONE GENVISC 850

HYALGAN HYMOVIS

MONOVISC ORTHOVISC

SUPARTZ FX SYNVISC

SYNVISC-ONE TRIVISC

DIRECT FACTOR XA INHIBITORSSAVAYSA

DISEASE-MODIFYING ANTIRHEUMATIC AGENTSACTEMRA ACTEMRA ACTPEN

AVSOLA CIMZIA

ENBREL ENBREL MINI

ENBREL SURECLICK HUMIRA

HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS

HUMIRA PEN PSOR-UVEITS-ADOL HS HUMIRA(CF)

HUMIRA(CF) PEDIATRIC CROHN'S HUMIRA(CF) PEN

HUMIRA(CF) PEN CROHN'S-UC-HS HUMIRA(CF) PEN PEDIATRIC UC

HUMIRA(CF) PEN PSOR-UV-ADOL HS INFLECTRA

KEVZARA KINERET

ORENCIA ORENCIA CLICKJECT

OTEZLA RINVOQ

SIMPONI SIMPONI ARIA

XELJANZ XELJANZ XR




DOPAMINE PRECURSORSINBRIJA

EENT ANTI-INFLAMMATORY AGENTS, MISC.RESTASIS RESTASIS MULTIDOSE

XIIDRA

EENT DRUGS, MISCELLANEOUSCYSTADROPS CYSTARAN

EYLEA LUCENTIS

OXERVATE

ENZYMESALDURAZYME CEREZYME

ELAPRASE ELELYSO

FABRAZYME HYQVIA HY COMPONENT

LUMIZYME NAGLAZYME

PALYNZIQ STRENSIQ

SUCRAID VPRIV

XIAFLEX

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTSCYCLOSET

FIBRIC ACID DERIVATIVESANTARA LIPOFEN

GI DRUGS, MISCELLANEOUSCHOLBAM ENDARI

ENTYVIO GATTEX

HUMIRA(CF) PEDIATRIC CROHN'S OCALIVA

SYMPROIC VIBERZI

GONADOTROPINSchorionic gonadotropin ELIGARD

FOLLISTIM AQ GONAL-F

GONAL-F RFF GONAL-F RFF REDI-JECT




GONADOTROPINS -- Continuedleuprolide acetate LUPRON DEPOT

LUPRON DEPOT (LUPANETA) LUPRON DEPOT-PED

MENOPUR NOVAREL

OVIDREL PREGNYL

SUPPRELIN LA SYNAREL

VANTAS ZOLADEX

HCV POLYMERASE INHIBITOR ANTIVIRALSEPCLUSA HARVONI

ledipasvir-sofosbuvir sofosbuvir-velpatasvir

SOVALDI VOSEVI

HCV PROTEASE INHIBITOR ANTIVIRALSMAVYRET

HCV REPLICATION COMPLEX INHIBITORSVIEKIRA PAK ZEPATIER

HEAVY METAL ANTAGONISTSCUPRIMINE D-PENAMINE

deferasirox deferiprone

DEPEN EXJADE

FERRIPROX FERRIPROX (2 TIMES A DAY)

FERRIPROX (3 TIMES A DAY) JADENU

JADENU SPRINKLE penicillamine

trientine hcl

HEMATOPOIETIC AGENTSARANESP DOPTELET

EPOGEN FULPHILA

GRANIX LEUKINE

MIRCERA MOZOBIL

MULPLETA NEULASTA

NEULASTA ONPRO NEUPOGEN




HEMATOPOIETIC AGENTS -- ContinuedNYVEPRIA PROCRIT

PROMACTA RETACRIT

UDENYCA ZARXIO

ZIEXTENZO

HEMOSTATICSADVATE ADYNOVATE

AFSTYLA ALPHANATE

ALPROLIX BENEFIX

COAGADEX ELOCTATE

ESPEROCT FEIBA NF

HELIXATE FS HEMLIBRA

HEMOFIL M HUMATE-P

IDELVION IXINITY

JIVI KOATE

KOGENATE FS KOVALTRY

MONONINE NOVOEIGHT

NOVOSEVEN RT NUWIQ

OBIZUR PROFILNINE

REBINYN RECOMBINATE

RIXUBIS SEVENFACT

TRETTEN VONVENDI

WILATE XYNTHA

XYNTHA SOLOFUSE

HIV INTEGRASE INHIBITOR ANTIRETROVIRALSVOCABRIA

HYPOTENSIVE AGENTS, MISCELLANEOUSVECAMYL

IMMUNOMODULATORY AGENTSACTIMMUNE AUBAGIO




IMMUNOMODULATORY AGENTS -- ContinuedAVONEX AVONEX PEN

BETASERON COPAXONE

dimethyl fumarate ENSPRYNG

EXTAVIA GILENYA

glatiramer acetate GLATOPA

KESIMPTA PEN MAYZENT

PLEGRIDY PLEGRIDY PEN

PONVORY REBIF

REBIF REBIDOSE THALOMID

TYSABRI VUMERITY

IMMUNOSUPPRESSIVE AGENTSASTAGRAF XL BENLYSTA

ENVARSUS XR everolimus

LUPKYNIS MAVENCLAD

ZORTRESS

INCRETIN MIMETICSSAXENDA

INTERFERON ANTIVIRALSINTRON A PEGASYS

PEGASYS PROCLICK PEGINTRON

SYLATRON

INTERLEUKIN ANTAGONISTSDUPIXENT PEN DUPIXENT SYRINGE

FASENRA FASENRA PEN

NUCALA

IRON PREPARATIONS



ACCRUFER

LEPTINS


LEPTINS -- ContinuedMYALEPT

LONG-ACTING INSULINSSOLIQUA 100-33 XULTOPHY 100-3.6

MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSCAROSPIR

MONOAMINE OXIDASE B INHIBITORSXADAGO

MONOBACTAM ANTIBIOTICSCAYSTON

MONOCLONAL ANTIBODY ANTIVIRALSSYNAGIS

MUCOLYTIC AGENTSPULMOZYME

NEUROKININ-1 RECEPTOR ANTAGONISTSAKYNZEO VARUBI

NITRATES AND NITRITESGONITRO

NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTSdihydroergotamine mesylate MIGRANAL

NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTAPOKYN KYNMOBI

NEUPRO

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSBARACLUDE HEPSERA

RIBASPHERE RIBASPHERE RIBAPAK

ribavirin SITAVIG




NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS -- Continued

OPIATE AGONISTSACTIQ fentanyl

fentanyl citrate hydrocodone bitartrate er

hydromorphone er methadone hcl

METHADONE INTENSOL METHADOSE

MORPHABOND ER morphine sulfate er

oxymorphone hcl er tramadol hcl er

XTAMPZA ER

OPIATE ANTAGONISTSVIVITROL

OPIATE PARTIAL AGONISTSBELBUCA BUNAVAIL

buprenorphine buprenorphine hcl

buprenorphine-naloxone BUTRANS

ZUBSOLV

OTHER MACROLIDE ANTIBIOTICSDIFICID

OTHER MISCELLANEOUS THERAPEUTIC AGENTSAMPYRA ARCALYST

BOTOX BOTOX COSMETIC

CERDELGA CYSTAGON

dalfampridine er DYSPORT

EVRYSDI FIRDAPSE

GALAFOLD ISTURISA

JEUVEAU KUVAN

miglustat nitisinone

NITYR ORFADIN

PROCYSBI RUZURGI

sapropterin dihydrochloride THIOLA




OTHER MISCELLANEOUS THERAPEUTIC AGENTS -- Continuedtiopronin ZAVESCA

ZOKINVY

OTHER NONSTEROIDAL ANTI-INFLAM. AGENTSINDOCIN VIVLODEX

OXABOROLESKERYDIN tavaborole

OXAZOLIDINONE ANTIBIOTICSSIVEXTRO ZYVOX

PARATHYROID AGENTSFORTEO NATPARA

teriparatide TYMLOS

PCSK9 INHIBITORSPRALUENT PEN REPATHA PUSHTRONEX

REPATHA SURECLICK REPATHA SYRINGE

PHOSPHODIESTERASE TYPE 4 INHIBITORSDALIRESP

PHOSPHODIESTERASE TYPE 5 INHIBITORSADCIRCA ALYQ

REVATIO sildenafil 20 mg tablet (pah)

sildenafil citrate tadalafil 20 mg tablet (pah)

PITUITARYNOCDURNA NORDITROPIN FLEXPRO

SEROSTIM ZORBTIVE

PITUITARY FUNCTIONMACRILEN

PLATELET-AGGREGATION INHIBITORS



ZONTIVITY


PLEUROMUTILINS

POTASSIUM-SPARING DIURETICSDYRENIUM triamterene

PROGESTINSDEPO-SUBQ PROVERA 104 hydroxyprogesterone caproate

MAKENA

PROKINETIC AGENTSGIMOTI MOTEGRITY

ZELNORM

QUINOLONE ANTIBIOTICSBAXDELA FACTIVE

RAPID-ACTING INSULINSAFREZZA

RESPIRATORY TRACT AGENTS, MISCELLANEOUSARALAST NP BRONCHITOL

GLASSIA PROLASTIN C

XOLAIR ZEMAIRA

RIFAMYCIN ANTIBIOTICSXIFAXAN

SALICYLATESDURLAZA

SELECTIVE SEROTONIN RECEPTOR AGONISTSBELVIQ BELVIQ XR

SELECTIVE-SEROTONIN REUPTAKE INHIBITORSPAXIL PEXEVA

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.ACCUTANE ACZONE

adapalene AMNESTEEM




SKIN AND MUCOUS MEMBRANE AGENTS, MISC. -- Continuedcalcipotriene-betamethasone dp CLARAVIS

DOVONEX DUPIXENT PEN

DUPIXENT SYRINGE FINACEA

isotretinoin KLISYRI

MYORISAN SILIQ

SKYRIZI SKYRIZI (2 SYRINGES) KIT

SKYRIZI PEN STELARA

TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (2 PACK)

TALTZ AUTOINJECTOR (3 PACK) TALTZ SYRINGE

TREMFYA WINLEVI

ZENATANE

SOMATOSTATIN AGONISTSBYNFEZIA MYCAPSSA

octreotide acetate SANDOSTATIN

SANDOSTATIN LAR DEPOT SIGNIFOR

SIGNIFOR LAR SOMATULINE DEPOT

SOMATOTROPIN AGONISTSEGRIFTA EGRIFTA SV

INCRELEX

THIAZOLIDINEDIONESAVANDIA

THYROID FUNCTIONTHYROGEN

VASOCONSTRICTORSADRENALIN CHLORIDE UPNEEQ

VASODILATING AGENTS (RESPIRATORY TRACT)ADEMPAS ambrisentan

bosentan FLOLAN

LETAIRIS OPSUMIT




VASODILATING AGENTS (RESPIRATORY TRACT) -- ContinuedREMODULIN TRACLEER

treprostinil TYVASO

TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT

TYVASO STARTER KIT UPTRAVI

VELETRI VENTAVIS

VASODILATING AGENTS, MISCELLANEOUSVERQUVO

VASOPRESSIN ANTAGONISTSJYNARQUE SAMSCA

tolvaptan

VESICULAR MONOAMINE TRANSPORT2 INHIBITORAUSTEDO INGREZZA

INGREZZA INITIATION PACK tetrabenazine

XENAZINE

VITAMIN DZEMPLAR

WAKEFULNESS-PROMOTING AGENTSarmodafinil modafinil

SUNOSI WAKIX



prior authorization drug list

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