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Prescription Drug Forms

Prior Authorization *

5 HI1 Agonist Post Limit
Abraxane®
Abstral®
Abraxane® (For Maryland Only)
Actemra® (Medical)
Actemra® (Pharmacy)
Acthar®
Acthar® (For Maryland Only)
Actimmune® (Medical)
Actimmune® (For Maryland Only)
Actimmune® (Pharmacy)
Actiq®
Adagen®
Adakveo®
Adcetris®
Adcirca®
Adempas®
Afstyla®
Afinitor®, Afinitor Disperz®
Afinitor® (For Maryland Only)
Aldurazyme®
Alecensa®
Alimta®
Alimta® (For Maryland Only)
Aliqopa™
Alphanate®, Humate-P,®, Koate-DVI®, Wilate®,
Alsuma®
Alunbrig®
Alunbrig® (for Maryland only)
Amerge®, Imitrex®, Maxalt®, Zomig®
Ampyra®
Ampyra® (For Maryland Only)
Antidiabetic Agents Step Therapy
Antifungal Topical Combinations Limit-Post Limit
Apokyn®, Kynmobi®
Aranesp®
Arcalyst®
Arikayce®
Arzerra®
Atacand®
Atralin®
AAT Deficiency: Aralast NP, Glassia, Prolastin-C, Zemaira
Atypical Antipsychotics®
Aubagio®
Aubagio® (For Maryland Only)
Austedo®
Avastin®, Mvasi®, Zirabev®
Avastin® (For Maryland Only)
Aveed®
Avita®
Avonex®
Avonex® (For Maryland Only)
Ayvakit™
Balversa®
Bavencio®
Bayer Contour Test Strip®
Bebulin VH®
Bendeka® (For Maryland Only)
Benlysta®
Beovu®
Berinert® (Medical)
Berinert® (Pharmacy)
Besponsa™
Betaseron® (For Maryland Only)
Bethkis®
Bexarotene®
Bivigam®
Bivigam® (For Maryland Only)
Blenrep®
Blincyto®
Bortezomib®
Bosulif®
Botox®
Bravelle®
Brineura®
Brineura® (For Maryland Only)
Brukinsa™
Buphenyl®
Buprenorphine®
Buprenorphine® Sublingual Tablets Post Limit
Butorphanol®
Cablivi®
Cabometyx®
Capecitabine®
Capecitabine® (For Maryland Only)
Carimune NF®
Carimune NF® (For Maryland Only)
Caprelsa®
Carbaglu®
Cayston®
Cerdelga®
Cerezyme®
Cetrotide®
Cholbam®
Cialis®
Cimzia® (Medical)
Cimzia® (Pharmacy)
Cinqair®
Cinryze® (Medical)
Cinryze® (Pharmacy)
Clindamycin®, Erythromycin Topical Limit-Post Limit
Coagadex®
Cometriq®
Compounded Drug Products®
Copaxone
Copaxone (For Maryland Only)
Copegus®
Copiktra®
Corifact®
Corticosteroid Topical Limit-Post Limit
Cosentyx® (Medical)
Cosentyx® (Pharmacy)
Cotellic®
Crysvita®
Cutaquig®
Cuvitru
Cystadane®
Cystagon®
Cyramza®
Cystaran®
Cytogam®
Dacogen®
Darzalex®
Darzalex Faspro®
Descovy® Step Therapy
Desferal®, deferoxamine®
Desvenlafaxine®
Diabetic Test Strips Medical Necessity
Docefrez®
Docefrez® (For Maryland Only)
Docetaxel®
Docetaxel® (For Maryland Only)
Doptelet®
Doxepin®
DPP-4 Inhibitors Step Therapy
Duopa™
Dupixent® Enhanced (Commercial)
Dupixent® (Exchange)
Dysport®
Egrifta®
Elaprase®
Elelyso®
Eligard®
Elidel®
Eloxatin®
Elzonris™
Emflaza®
Empliciti®
Emverm®
Enbrel®
Enhertu®
Enspryng®
Entresto®
Entyvio®
Entyvio® (Medical) (For Maryland Only)
Epidiolex®
Epinephrine Injectable Limit-Post Limit
Epogen® (Medical)
Epogen®, Procrit®, Retacrit® (Pharmacy)
Erbitux®
Erbitux® (For Maryland Only)
Erivedge®
Erwinaze®
Esbriet®
Esperoct®
Euflexxa®
Euflexxa® (For Maryland Only)
Evenity®
Evrysdi®
Exelderm Limit-Post Limit
Exondys 51®
Extavia®
Extavia® (For Maryland Only)
Extina® Limit-Post Limit
Eylea®
Fabior®
Fabrazyme®
Factor IX, Factor IX Complex: Alprolix, Benefix, Ixinity, Idelvion, Rixubis, Alphanine SD, Mononine, Rebinyn
Factor VIII: Advate®, Eloctate®, Helixate FS®, Hemofil M®, Kogenate FS®, Kovaltry®, Monoclate-P®, Novoeight®, Nuwiq®, Recombinate®, Xyntha®, Jivi®, Adynovate®
Farydak®
Fasenra® 
Faslodex®
Feiba®
Fensolvi®
Fentanyl Cirtate Oral Tra®
Fentora®
Ferriprox®
Fibryga®
Firmagon®
Flebogamma®
Flebogamma® (For Maryland Only)
Flolan®, Veletri® , and Epoprostenol®
Follistim AQ®
Folotyn®
Forteo®
Fortament®
Fortament® (For Maryland Only)
Freestyle Test Strips® Post Limit
Frova® Post Limit
Fusilev®
Fuzeon®
GamaSTAN®
Gamifant®
Gammagard®
Gammagard® (For Maryland Only)
Gammaked®
Gammaked® (For Maryland Only)
Gammaplex®
Gammaplex® (For Maryland Only)
Gamunex®
Gamunex® (For Maryland Only)
Ganirelix Acetate®
Gattex®
Gattex®
Gazyva®
Gel-One® (For Maryland Only)
Gemcitabine®
Generic Step Therapy - Acne
Genotropin®
Genotropin® (For Maryland Only)
Gilenya®
Gilenya® (For Maryland Only)
Gilotrif®
Givlaari®
Glatopa®
Glatopa® (For Maryland Only)
Glumetza®
Glumetza® (For Maryland Only)
GONAL-F®
GONAL-F RFF®
Granix®
Granix® (For Maryland Only)
Growth Hormone (Medical)
Growth Hormone (Pharmacy)
Haegarda®
Halaven® 
Hemlibra®
Hepatitis C Therapies: Daklinza®, Epclusa®, Harvoni®, Mavyret®, Moderiba®, Olysio®, Pegasys®, Ribasphere RibaPak®, ribavirin®, Sovaldi®, Technivie®, Viekira®, Viekira XR®, Vosevi®, Zepatier®
Hereditary Angioedema
Herceptin Hylecta®
Herceptin®, Kanjinti®, Ogivri®, Herzuma®, Ontruzant®, Trazimera®
Herceptin® (for Maryland)
Hetlioz®
High Risk Medications
Hizentra®
Humatrope®
Humira®
Humira® (For Maryland Only)
Hyalgan®
Hyalgan® (For Maryland Only)
Hycamtin®
HyQvia®
Ibrance®
Icatibant®
Iclusig®
Ilaris®
Ilaris® (For Maryland Only)
Ilumya®
Imatinib®
Imbruvica®
Imbruvica® (For Maryland Only)
Imfinzi®
Imlygic®
Immune Globulins
Increlex® (Medical)
Increlex® (Pharmacy)
Infertility
Influenza Treatment
Infugem™
Ingrezza®
Inlyta®
Inqovi®
Inrebic®
Intron A®
Intron A® (For Maryland Only)
Intuniv-Kapvay
Iressa®
Istodax®
Ixempra®
Jadenu®
Jakafi®
Jakafi® (For Maryland Only)
Jetrea®
Jevtana® 
Jublia® Limit-Post Limit
Juxtapid®
Juxtapid® (For Maryland Only)
Kadcyla®
Kalbitor®
Kalbitor® (for Maryland only)
Kalydeco®
Kanuma®
Kevzara®
Keytruda®
Kineret®
Kisqali Femara® Co-Pack
Kitabis Pak®
Kisqali®
Korlym®
Krystexxa®
Kuvan®
Kymriah®
Kynamro®
Kynamro® (For Maryland Only)
Kyprolis®
Lartruvo®
Lazanda®
Lemtrada®
Lenvima®
Lenvima® (For Maryland Only)
Letairis®
Leukine®
Leuprolide Acetate
Libtayo®
Lidocaine Limit-Post Limit®
Lorbrena®
Lonsurf®
Lonsurf® (for Maryland only)
Lovaza®
Lucentis®
Lumizyme®
Lumoxiti®
Lupron Hormonal®
Lutathera®
Luxturna®
Lynparza®
Lynparza® (For Maryland Only)
Lyrica, Gralise, Horizant
Macugen®
Makena®
Mekinist®
Menopur®
Mepsevii®
Mircera®
Mitoxantrone®
Monjuvi®
Monovisc®
Monovisc® (For Maryland Only)
Mulpleta®
Multiple Sclerosis
Mupirocin Limit-Post Limit
Myalept® (Medical)
Myalept® (Pharmacy)
Myobloc®
Myozyme®
Naglazyme®
Natpara®
Natesto®
Natesto® (For Maryland Only)
Nerlynx®
Nerlynx® (For Maryland Only)
Neulasta®, Fulphila®, Udenyca®, Ziextenzo®, Nyvepria®
Neumega®
Neupogen®,Granix®, Zarxio®, Nivestym®
New to Market Drugs;
New to Market Drugs (For Maryland Only)
Nexavar®
Ninlaro®
Northera®
Nesina® (For Maryland Only)
NovoSeven RT®
Noxafil®
Nplate® (Medical)
Nplate®, Promacta®, (Pharmacy)
Nubeqa®
Nucala®
Nuplazid®
Nutropin AQ®
Obizur®
Ocaliva®
Ocaliva® (for Maryland only)
Ocrevus®
Octagam®
Octagam® (For Maryland Only)
Octreotide Acetate® (For Maryland Only)
Odomzo®
Ofev®
Olumiant ®
Omega 3 Fatty Acids
Omnitrope®
Omnitrope® (For Maryland Only)
Oncaspar®
One Touch® Test Strips
One Touch Verio® Test Strips
Onpattro®
Onsolis®
Opdivo®
Opioids ER - Step Therapy with MME Limit and Post Limit
Opioids IR - Acute Pain Duration Limit with MME Limit and Post Limit
Opioids IR - 3-Day Acute Pain Duration Limit for 19 and Under with MME Limit and Post Limit
Opioids IR - 3-Day APAP-ASA-IBU Combo Products - Acute Pain Duration Limit for 19 and Under
Opsumit®
Oral Pain Meds
Orencia® (Medical)
Orencia® (Pharmacy)
Orenitram®
Orkambi®
Orthovisc®
Orthovisc® (For Maryland Only)
Osteoarthritis 
Orfadin®
Otezla®
Otezla® (For Maryland Only) (Formulary 1 and 2)
Otezla® (For Maryland Only) (Formulary 3)
Otrexup®
Otrexup® (For Maryland Only)
Ovidrel®
Oxervate®
Oxbryta™
Oxlumo®
Padcev®
Pancrelipase®
Panzyga®
Parsabiv®
Peg-Intron®
Pennsaid®
Perjeta®
Phesgo®
Plegridy®
Plegridy® (For Maryland Only)
Polivy™
Pomalyst®
Pomalyst® (For Maryland Only)
Poteligeo®
Praluent®
Praluent® (For Maryland Only)
Pregnyl®
Privigen®
Privigen® (For Maryland Only)
Procrit® (Medical)
Procysbi®
Proleukin®
Prolia®
Prolia® (Medical)
Prolia® (For Maryland Only)
Promacta®
Promacta® (For Maryland Only)
Protopic®
Provenge® (For Maryland Only)
Prudoxin®, Zonalon® (Step Therapy)
Pulmozyme®
Purixan®
Qinlock®
Radicava®
Ranexa®
Rasuvo®
Rasuvo® (For Maryland Only)
Ravicti®
Rebetol®
Reclast®
Reclast® (For Maryland Only)
Regranix®
Remicade®, Inflectra®, Renflexis®, Avsola®
Remodulin®, treprostinil®
Repatha®
Replax Post Limit®
Repronex®
Retacrit® (Medical)
Retevmo®
Retin-A®
Revatio®
Revlimid®
RiaSTAP®
Rituxan®, Ruxience, Truxima
Rituxan Hycela
Rinvoq®
Rozlytrek®
Rubraca®
Rubraca® (For Maryland Only)
Ruconest®
Rydapt®
Sabril®
Sabril® (For Maryland Only)
Saizen®
Samsca®
Sandostatin, Sandstatin® LAR Bynfezia octreotide (Medical)
Sandostatin, Sandostatin LAR Depot (Pharmacy)
Scenesse®
Self Injectables
Serostim®
Serostim® (For Maryland Only)
Sensipar®
Sevenfact®
Signifor LAR®
Sildenafil®
Siliq®
Simponi Aria® (Medical)
Simponi®, Simponi Aria® (Pharmacy)
Skyrizi
Sodium Phenylbutyrate
Solaraze®
Soliris®
Solodyn®
Solodyn® (For Maryland Only)
Somatuline Depot®
Somavert®
Spinraza®
Sprycel®
Spravato®
Stelara® (Medical)
Stelara® (Pharmacy)
Stimate®
Stivarga®
Stivarga® (For Maryland Only)
Strensiq®
Subsys®
Sucraid®
Supartz®
Supartz® (For Maryland Only)
Supprelin LA®
Sutent®
Sylatron® (Medical)
Sylatron® (Pharmacy)
Sylvant®
Synagis®
Synribo®
Synvisc®
Synvisc® (for Maryland only)
Tabrecta®
Tafinlar®
Tagrisso®
Tagrisso® (for Maryland only)
Takhzyro®
Tamiflu Post Limit®
Taltz®
Tarceva®
Targretin®
Tasigna®
Tasigna® (For Maryland Only)
Taxotere®
Tavalisse®
Taxotere® (For Maryland Only)
Tazorac®
Tazverik™
Tecartus®
Tecentriq®
Tecfidera®
Tecfidera® (For Maryland Only)
Tegsedi®
Temodar®
Temozolomide®
Tepezza®
Terbinafine®
Tetrabenazine®
Thalomid®
Tikosyn®
TOBI®
Tobramycin®
Torisel®
Tracleer®
Treanda®, Bendeka®, Belrapzo®
Treanda® (For Maryland Only)
Trelstar®
Tremfya®
Tretten®
Tretin-X®
Treximet Post Limit®
Trentinoins
Triptodur®
Trodelvy®
Turalio®
Tukysa ®
Tykerb®
Tymlos®
Tymlos® (For Maryland Only)
Tysabri®
Tysabri® (For Maryland Only)
Tyvaso®
Uplizna®
Uptravi®
Uloric®
Ultomiris®
Valchlor®
Vantas®
Vascepa®
Vectibix®
Velcade®
Vemlidy®
Venclexta®
Venclexta® (For Maryland Only)
Ventavis®
Verzenio®
Victrelis®
Vidaza®
Viltepso®
Vimizim®
Visco-3®
Visco-3® (Maryland Only)
Visudyne®
Vonvendi®
Votrient®
VPRIV®
Vumerity™
Vyepti®
Vyondys™53
Vytorin®
Wakix®
Xartemis® XR MME Limit
Xalkori®
Xeljanz®, Xeljanz XR®
Xeloda®
Xembify®
Xenazine®
Xeomin®
Xermelo®
Xermelo® (for Maryland only)
Xgeva®
Xgeva® (For Maryland Only)
Xiaflex®
Xifaxan®
Xolair®
Xospata®
Xtandi®
Xyrem®
Yervoy®
Yescarta®
Zaltrap®
Zarxio®
Zavesca®
Zejula®
Zelboraf®
Zirabev™
Zoladex®
Zolgensma®
Zolinza®
Zomacton®
Zometa®, Zoledronic Acid®
Zokinvy®
Zorbtive®
Zulresso®
Zydelig®
Zyflo®
Zykadia®
Zytiga®