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 |
