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Prescription Drug Forms

Prior Authorization *

5 HI1 Agonist Post Limit
Abraxane®
Abstral®
Actemra® (Medical)
Actemra® (Pharmacy)
Acthar®
Actimmune® (Medical)
Actimmune® (Pharmacy)
Actiq®
Adagen®
Adakveo®
Adcetris®
Adcirca®
Adempas®
Afstyla®
ADHD Agents Post Limit
Afinitor®, Afinitor Disperz®
Aldurazyme®
Alecensa®
Alimta®
Aliqopa™
Alphanate®, Humate-P,®, Koate-DVI®, Wilate®,
Alsuma®
Alunbrig®
Amerge®, Imitrex®, Maxalt®, Zomig®
Ampyra®
Antidiabetic Agents Step Therapy
Antiemetics Post Limit
Antifungal Topical Step Therapy (HMF)
Apokyn®, Kynmobi®
Aranesp®
Arcalyst®
Arikayce®
Arzerra®
Atacand®
Atralin®
AAT Deficiency: Aralast NP, Glassia, Prolastin-C, Zemaira
Atypical Antipsychotics®
Aubagio®
Austedo®
Avastin®, Mvasi®, Zirabev®
Aveed®
Avita®
Avonex®
Ayvakit™
Balversa®
Bavencio®
Bayer Contour Test Strip®
Bebulin VH®
Benlysta®
Beovu®
Berinert® (Medical)
Berinert® (Pharmacy)
Besponsa™
Bethkis®
Bexarotene®
Bivigam®
Blenrep®
Blincyto®
Bortezomib®
Bosulif®
Botox®
Braftovi ®
Bravelle®
Breyanzi®
Brineura®
Bronchitol®
Brukinsa™
Buphenyl®
Buprenorphine®
Buprenorphine SL Tablets (VF Standard)
Buprenorphine® Sublingual Tablets Post Limit
Butorphanol®
Cablivi®
Cabometyx®
Calquence®
Capecitabine®
Carbaglu®
Carimune NF®
Caprelsa®
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
Copegus®
Copiktra®
Corifact®
Corticosteroid Topical Limit-Post Limit
Cosentyx® (Medical)
Cosentyx® (Pharmacy)
Cotellic®
Crysvita®
Cutaquig®
Cuvitru
Cystadane®
Cystagon®
Cyramza®
Cystaran®
Cytogam®
Dacogen®
Daliresp®
Darzalex®
Darzalex Faspro®
Descovy®, Truvada®
Desferal®, deferoxamine®
Desvenlafaxine®
Diabetic Test Strips Medical Necessity
Docefrez®
Docetaxel®
Doptelet®
Doxepin®
DPP-4 Inhibitors Step Therapy
Dronabinol Post Limit
Duopa™
Dupixent® Enhanced (Commercial)
Dupixent® (Exchange)
Dysport®
Egrifta®
Elaprase®
Elelyso®
Eligard®
Elidel®
Eloxatin®
Elzonris™
Emflaza®
Empliciti®
Emverm® Post Limit
Enbrel®
Enhertu®
Enspryng®
Entresto®
Entyvio®
Epidiolex®
Epinephrine Injectable Limit-Post Limit
Epogen®,Procrit®, Retacrit® (Medical)
Epogen®, Procrit®, Retacrit® (Pharmacy)
Erbitux®
Erivedge®
Erwinaze®
Esbriet®
Esperoct®
Euflexxa®
Evenity®
Evkeeza®
Evrysdi®
Exelderm Limit-Post Limit
Exelon
Exondys 51®
Extavia®
Extina® Limit-Post Limit
Eylea®
Fabior®
Fabrazyme®
Factor IX, Factor IX Complex: Alprolix, Benefix, Bebulin, Ixinity, Idelvion, Rixubis, Alphanine SD, Mononine, Profilnine, 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®
Flolan®, Veletri® , and Epoprostenol®
Follistim AQ®
Folotyn®
Forteo®
Fortament®
Fotivda®
Freestyle Test Strips® Post Limit
Frova® Post Limit
Fusilev®
Fuzeon®
GamaSTAN®
Gamifant®
Gammagard®
Gammaked®
Gammaplex®
Gamunex®
Ganirelix Acetate®
Gattex®
Gattex®
Gazyva®
Gemcitabine®
Generic Step Therapy - Acne
Genotropin®
Gilenya®
Gilotrif®
Givlaari®
Glatopa®
Glumetza®
GONAL-F®
GONAL-F RFF®
Granix®
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®
Hetlioz®
High Risk Medications
Hizentra®
Humatrope®
Humira®
Hyalgan®
Hycamtin®
HyQvia®
Ibrance®
Icatibant®
Iclusig®
Idhifa®
Ilaris®
Ilumya®
Imatinib®
Imbruvica®
Imfinzi®
Imlygic®
Immune Globulins
Increlex® (Medical)
Increlex® (Pharmacy)
Infertility
Influenza Post Limit (VF Standard)
Influenza Treatment
Infugem™
Ingrezza®
Inlyta®
Inqovi®
Inrebic®
Insomnia Agents Post Limit
Intron A®
Intuniv-Kapvay
Iressa®
Istodax®
Ixempra®
Jadenu®
Jakafi®
Jetrea®
Jevtana® 
Jublia® Limit-Post Limit
Juxtapid®, Kynamro®
Kadcyla®
Kalbitor®
Kalydeco®
Kanuma®
Kevzara®
Keytruda®
Kineret®
Kisqali Femara® Co-Pack
Kitabis Pak®
Kisqali®
Korlym®
Krystexxa®
Kuvan®
Kymriah®
Kyprolis®
Lartruvo®
Lazanda®
Lemtrada®
Lenvima®
Letairis®
Leukine®
Leuprolide Acetate
Libtayo®
Lidocaine Topical Post Limit
Lorbrena®
Lupron® Hormonal
Lonsurf®
Lovaza®
Lucentis®
Lumizyme®
Lumoxiti®
Lumoxiti®
Lupkynis®
Lutathera®
Luxturna®
Lynparza®
Lyrica, Gralise, Horizant
Macugen®
Makena®
Mekinist®
Mektovi®
Menopur®
Mepsevii®
Mircera®
Mitoxantrone®
Monjuvi®
Monovisc®
Mulpleta®
Multiple Sclerosis
Mupirocin Limit-Post Limit
Myalept® (Medical)
Myalept® (Pharmacy)
Myobloc®
Myozyme®
Naglazyme®
Namenda®
Natpara®
Natesto®
Nerlynx®
Neulasta®, Fulphila®, Udenyca®, Ziextenzo®, Nyvepria®
Neumega®
Neupogen®,Granix®, Zarxio®, Nivestym®
New to Market Drugs;
New to Market Drugs (For Maryland Only)
Nexavar®
Ninlaro®
Northera®
NovoSeven RT®
Noxafil®
Nplate® (Medical)
Nplate®, Promacta®, (Pharmacy)
Nubeqa®
Nucala®
Nuplazid®
Nutropin AQ®
Obizur®
Ocaliva®
Ocrevus®
Octagam®
Odomzo®
Ofev®
Olumiant ®
Omega 3 Fatty Acids
Omnitrope®
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®
Osteoarthritis 
Orfadin®
Otezla®
Otrexup®, Rasuvo®
Ovidrel®
Oxervate®
Oxbryta™
Oxlumo®
Padcev®
Palynziq®
Pancrelipase®
Panzyga®
Parsabiv®
Peg-Intron®
Pennsaid®
Perjeta®
Phesgo®
Plegridy®
Polivy™
Pomalyst®
Proton Pump Inhibitors Post Limit
Poteligeo®
Praluent®
Pregnyl®
Privigen®
Procrit® (Medical)
Procysbi®
Proleukin®
Prolia®
Promacta®
Protopic®
Prudoxin®, Zonalon® (Step Therapy)
Pulmozyme®
Purixan®
Qinlock®
Radicava®
Ranexa®
Rasuvo®
Ravicti®
Rebetol®
RediTrex®
Reclast®
Regranix®
Remicade®, Inflectra®, Renflexis®, Avsola®
Remodulin®, treprostinil®
Repatha®
Replax Post Limit®
Repronex®
Retacrit® (Medical)
Retevmo®
Retin-A®
Revatio®
Revlimid®
Reyvow®
RiaSTAP®
Rituxan®, Ruxience,®, Truxima®, Riabni®
Rituxan Hycela
Rinvoq®
Rozlytrek®
Rubraca®
Ruconest®
Rydapt®
Sabril®
Saizen®
Samsca®
Sandostatin, Bynfezia, Mycapssa (Pharmacy)
Scenesse®
Self Injectables
Serostim®
Sensipar®
Sevenfact®
Signifor LAR®
Sildenafil®
Siliq®
Simponi Aria® (Medical)
Simponi®, Simponi Aria® (Pharmacy)
Skyrizi
Sodium Phenylbutyrate
Solaraze®
Soliris®
Solodyn®
Somatuline Depot®
Somavert®
Spinraza®
Sprycel®
Spravato®
Stelara® (Medical)
Stelara® (Pharmacy)
Stimate®
Stivarga®
Strensiq®
Subsys®
Sucraid®
Supartz®
Supprelin LA®
Sutent®
Sylatron® (Medical)
Sylatron® (Pharmacy)
Sylvant®
Synagis®
Synribo®
Synvisc®
Tabrecta®
Tafinlar®
Tagrisso®
Takhzyro®
Tamiflu Post Limit®
Taltz®
Tarceva®
Targretin®
Tasigna®
Taxotere®
Tavalisse®
Tazorac®
Tazverik™
TCA Agents (Elderly) Post Limit
Tecartus®
Tecentriq®
Tecfidera®
Tegsedi®
Temodar®
Temozolomide®
Tepezza®
Tepmetko®
Terbinafine®
Tetrabenazine®
Thalomid®
Thiola®
Tibsovo®
Tikosyn®
TOBI®
Tobramycin®
Torisel®
Tracleer®
Treanda®, Bendeka®, Belrapzo®
Trelstar®
Tremfya®
Tretten®
Tretin-X®
Treximet Post Limit®
Trentinoins
Triptodur®
Trikafta®
Trodelvy®
Turalio®
Tukysa ®
Tykerb®
Tymlos®
Tysabri®
Tyvaso® (Medical)
Tyvaso® (Pharmacy)
Uplizna®
Uptravi®
Ukoniq®
Uloric®
Ultomiris®
Valchlor®
Vantas®
Vascepa®
Vectibix®
Velcade®
Vemlidy®
Venclexta®
Ventavis®
Verzenio®
Victrelis®
Vidaza®
Viltepso®
Vimizim®
Visco-3®
Visudyne®
Vonvendi®
Votrient®
VPRIV®
Vumerity™
Vyepti®
Vyondys™53
Vytorin®
Wakix®
Xartemis® XR MME Limit
Xalkori®
Xeljanz®, Xeljanz XR®
Xeloda®
Xembify®
Xenazine®
Xeomin®
Xermelo®
Xgeva®
Xiaflex®
Xifaxan®
Xolair®
Xospata®
Xpovio®
Xtandi®
Xyrem®
Yervoy®
Yescarta®
Zaltrap®
Zarxio®
Zavesca®
Zegerid®
Zejula®
Zelboraf®
Zirabev™
Zoladex®
Zolgensma®
Zolinza®
Zomacton®
Zometa®, Zoledronic Acid®
Zokinvy®
Zorbtive®
Zulresso®
Zydelig®
Zyflo®
Zykadia®
Zytiga®