Policy Name |
Adalimumab (Humira®) |
Age Edits for Pharmaceuticals Covered Under the Pharmacy Benefit |
Anakinra (Kineret®) |
Armodafinil (Nuvigil®) |
Atorvastatin (Lipitor®) / Amlodipine/atorvastatin (Caduet®) |
Budesonide/Formoterol Fumarate Dihydrate (Symbicort®) |
Calcipotriene and betamethasone dipropionate (Taclonex®/Taclonex Scalp®) |
Calcitriol (Vectical) Ointment |
Certolizumab (Cimzia®) Prefilled Syringe |
Ciclesonide (Alvesco™) |
Contraceptive Agents |
Controlled Substance Prior Authorization |
Controlled Substance Quantity Limits |
Cyclobenzaprine hydrochloride extended-release (Amrix®) |
Cyclooxygenase-2 (COX-2) Inhibitors and Meloxicam (Mobic®) |
Deferasirox (Exjade®) |
Desvenlafaxine (Pristiq™) |
Diclofenac epolamine 1.3% (Flector® Patch) |
Diclofenac sodium 1% (Voltaren® Gel) |
Doxycycline hyclate (Alodox™) |
Doxycycline monohydrate 75 mg capsules convenience kit (Nutridox™) |
Duloxetine (Cymbalta®) |
Efalizumab (Raptiva®) |
Erectile Dysfunction Agents |
Etanercept (Enbrel®) |
Exenatide (Byetta®) |
Experimental/Investigational/Off-label Drug Use |
Ezetimibe/simvastatin (Vytorin®) |
Fenofibric Acid (Trilipix) |
Fluticasone Furoate (Veramyst®) Nasal Spray |
Gender Edits |
Golibumab (Simponi™) |
Growth Hormones |
Injectable Fertility Medications |
Isosorbide Dinitrate and Hydralazine Hydrochloride (BiDil®) |
Lacosamide (Vimpat) (Oral) |
Levocetirizine (Xyzal®) |
Lisdexamfetamine Dimesylate (Vyvanse®) |
Mecasermin (Increlex™) |
Methylphenidate Transdermal System (Daytrana®) |
Migraine Agents |
Modafinil (Provigil®) |
Montelukast (Singulair®) |
Nabilone (Cesamet®) |
Niacin Extended-Release/Simvastatin (Simcor®) |
Nonformulary Medication Requests |
Non-Preferred Diabetic Test Strips |
Olopatadine Hydrochloride (Pataday™) 0.2 Percent |
Omalizumab (Xolair®) |
Oral Antihypertensive Agents |
Oral Anti-infective Agents |
Oral Chemotherapy Agents |
Oral Diabetic Agents |
Paliperidone (Invega®) |
Pramlintide (Symlin®/SymlinPen®) |
Prasugrel (Effient™) |
Pregabalin (Lyrica®) |
Proton Pump Inhibitors |
Quantity Level Limits for Pharmaceuticals Covered Under the Pharmacy Benefit |
Quetiapine fumarate (Seroquel XR®) |
Quinine Sulfate (Qualaquin™) |
Ranolazine (Ranexa®) |
Repaglinide and Metformin hydrochloride (PrandiMet™) |
Retapamulin (Altabax®) |
Ropinirole extended-release tablets (Requip® XL™) |
Rosuvastatin calcium (Crestor®) |
Rufinamide (Banzel™) |
Saxagliptin (Onglyza™) |
Schedule II Prior Authorization |
Schedule II Quantity Level Limits |
Selegiline HCl (Zelapar®) |
Sevelamer Carbonate (Renvela) |
Sildenafil (Revatio®) |
Sleep Agents |
Sumatriptan and naproxen sodium (Treximet™) |
Tadalafil (Adcirca™) |
Tapentadol (Nucynta™) |
Teriparatide (Forteo™) (rDNA origin) Injection |
Tetrabenazine (Xenazine) |
Topical Retinoid Products |
Tramadol Extended-Release (ER) (Ultram ER®) |
Tramadol Extended Release (Ryzolt) |
Weight Loss Agents |