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    Pharmacy Prior Authorization

    Drug Prior Authorization

    Prior authorization requests must be submitted electronically through the CareFirst Provider Portal for all drugs requiring prior authorization.

    If you are already using the CareFirst Provider Portal, login at www.carefirst.com/providerlogin, and click on the Prior Auth/Notifications tab to begin your request. If you are not yet registered to use the Provider Portal, you can do so at www.carefirst.com/carefirstdirect.

    Questions?

    If you are experiencing technical difficulties with the Provider Portal, please contact the CareFirst Help Desk at 877-526-8390.

    For all other questions regarding the submission of your request, please contact CVS Caremark:

    • For specialty drugs: 888-877-0518
    • For non-specialty drugs: 855-582-2038
    • For FEP drugs requiring online prior authorization: 800-469-7556

    For more information on submitting drug prior authorization electronically, view our training video or download the user guide.

    Jump To:

    #

    Drug Name
    Drug Criteria
    5H1 Agonsit Post QL PA® 5H1 Agonsit Post QL PA®

    A

    Drug Name
    Drug Criteria
    Abilify® Abilify®
    Abraxane® Abraxane®
    Abstral® Abstral®
    Acamprosate Calcium (Exchange Only) Acamprosate Calcium (Exchange Only)
    Accu-Check Aviva Plus Test Strips Accu-Check Aviva Plus Test Strips Policy
    Actemra IV® Actemra IV®Policy
    Actemra SQ® Actemra SQ® Policy
    Acthar® Acthar® Policy
    Actimmune® Actimmune® Policy
    Actiq® Actiq® Policy
    Actos Actos®
    Adagen® Adagen® Policy
    Adcetris ® Adcetris ® Policy
    Adcirca® Adcirca® Policy
    Adderall XR® Adderall XR®
    Adempas® Adempas® Policy
    ADHD Agents Quantity Limit (Exchange Only) ADHD Agents Quantity Limit (Exchange Only)
    Adrenaclick® Adrenaclick®
    Advate® Advate® Policy
    Advicor® Advicor®
    Aerospan® Aerospan®
    Afinitor® Afinitor® Policy
    Afstyla ® Afstyla® Policy
    Albenza® Albenza® Policy
    Alcortin A® Alcortin A® Policy
    Aldurazyme® Aldurazyme® Policy
    Alecensa® Alecensa® Policy
    Alferon® Alferon® Policy
    Allison Medical Insulin Syringes® Allison Medical Insulin Syringes® Policy
    Alimta® Alimta® Policy
    Aloquin® Aloquin® Policy
    Alphanate® Alphanate® Policy
    Alphanine SD® Alphanine SD® Policy
    Alprolix® Alprolix® Policy
    Alsuma® Alsuma® Policy
    Altoprev® Altoprev®
    Alunbrig® Alunbrig®
    Alvesco® Alvesco®
    Ampyra® Ampyra® Policy
    Amrix® Amrix®
    Anabolic Steroids - Anadrol 50 (Exchange Only)® Anabolic Steroids - Anadrol 50 (Exchange Only)®
    Anabolic Steroids - Oxandrin (Exchange Only)® Anabolic Steroids - Oxandrin (Exchange Only)®
    Androgel® Androgel®
    Anti-Anxiety Agents Quantity Limit (Exchange Only) Anti-Anxiety Agents Quantity Limit (Exchange Only)
    Anticholinergic, Combination, Mast Cell Stabilizer Oral Inhalation Quantity Limit (Exchange Only) Anticholinergic, Combination, Mast Cell Stabilizer Oral Inhalation Quantity Limit (Exchange Only)
    Antidiabetic Agents Step Therapy (Exchange Only) Antidiabetic Agents Step Therapy (Exchange Only)
    Anticholinergic, Combination, Mast Cell Stabilizer Oral Inhalation Quantity Limit (Exchange Only) Anticholinergic, Combination, Mast Cell Stabilizer Oral Inhalation Quantity Limit (Exchange Only)
    Antifungal Topical Step Therapy (Exchange Only) Antifungal Topical Step Therapy (Exchange Only)
    Antihistamine, Steroid, Combination Intranasal Quantity Limit (Exchange Only) Antihistamine, Steroid, Combination Intranasal Quantity Limit (Exchange Only)
    Apexicon E PA-ECX® Apexicon E PA-ECX®
    Apidra FA-EXC® Apidra®
    Apokyn® Apokyn® Policy
    Aptiom (Exchange Only)® Aptiom (Exchange Only)® Policy
    Aralast NP® Aralast NP® Policy
    Aranesp® Aranesp® Policy
    Arcalyst® Arcalyst® Policy
    Arthrotec® Arthrotec®
    Asacol-HD® Asacol®
    Atacand® Atacand®
    Atacand HCT® Atacand HCT®
    Atralin® Atralin® Policy
    Atypical Antipsychotics Step Therapy (Exchange Only) Atypical Antipsychotics Step Therapy (Exchange Only)
    Austedo® Austedo® Policy
    Aubagio® Aubagio® Policy
    Avastin® Avastin® Policy
    Aveed® Aveed® Policy
    Avita® Avita® Policy
    Avonex® Avonex® Policy
    Azacitidine® Azacitidine® Policy

    B

    Drug NameDrug Criteria
    Banzel® (Exchange Only) Banzel® (Exchange Only)
    Bavencio® Bavencio®
    Bayer Contour Test Strips® Bayer Contour Test Strips®
    Bebulin VH® Bebulin VH®
    Beconase AQ Policy® Beconase AQ Policy®
    Bendeka® Bendeka®
    Benefix® Benefix®
    Benlysta® Benlysta®
    Berinert® Berinert®
    Betapace® Betapace®
    Betapace AF® Betapace AF®
    Betaseron® Betaseron®
    Bethkis® Bethkis®
    Bexarotene® Bexarotene®
    Biltricide® Biltricide®
    Bivigam® Bivigam®
    Bosulif® Bosulif®
    Botox® Botox®
    BPH Cialis® 2.5mg, 5mg (Exchange Only) BPH Cialis® 2.5mg, 5mg (Exchange Only)
    Bravelle® Bravelle®
    Breeze 2 Test Strips and Kits4® Breeze 2 Test Strips and Kits4®
    Brineura® Brineura®
    Buphenyl® Buphenyl®
    Beta Agonists-Long Acting, Combination Oral Inhalation Quantity Limit (Exchange Only) Beta Agonists-Long Acting, Combination Oral Inhalation Quantity Limit (Exchange Only)
    Beta Agonists-Short Acting Oral Inhalation Quantity Limit (Exchange Only) Beta Agonists-Short Acting Oral Inhalation Quantity Limit (Exchange Only)
    Betapace AF® Betapace AF®
    Buprenorphine Quantity Limit and Post Limit (Exchange Only) Buprenorphine Quantity Limit and Post Limit (Exchange Only)
    Buprenorphine-Naloxone Quantity Limit (Exchange Only) Buprenorphine-Naloxone Quantity Limit (Exchange Only)
    Butalbital-acetaminophen-caffeine capsule® Butalbital-acetaminophen-caffeine capsule®
    Butalbital Products Quantity Limit (Exchange Only) Butalbital Products Quantity Limit (Exchange Only)
    Bydureon® Bydureon®
    Byetta® Byetta®

    C

    Drug NameDrug Criteria
    Cabometyx® Cabometyx®
    Cafergot® Cafergot®
    Capecitabine® Capecitabine®
    Caprelsa® Caprelsa®
    Carac® Carac®
    Carbaglu® Carbaglu®
    Cardizem® Cardizem®
    Cardizem CD® Cardizem CD®
    Cardizem LA® Cardizem LA®
    Carimune NF® Carimune NF®
    Carnitor® Carnitor®
    Carnitor SF® Carnitor SF®
    Cayston® Cayston®
    Cesamet® Quantity Limit (Exchange Only) Cesamet® Quantity Limit (Exchange Only)
    Cerdelga® Cerdelga®
    Cerezyme® Cerezyme®
    Cetrotide® Cetrotide®
    Cholbam® Cholbam®
    Chorionic Gonadotropins® (Exchange Only) Chorionic Gonadotropins® (Exchange Only)
    Cimzia® Cimzia®
    Cinqair® Cinqair®
    Cinryze® Cinryze®
    Clobetasol Spray® Clobetasol Spray®
    Clobex Spray® Clobex Spray®
    Coagadex® Coagadex®
    Cometriq® Cometriq®
    Compounded Drug Products® Compounded Drug Products®
    Copaxone® Copaxone®
    Copegus® Copegus®
    Corifact® Corifact®
    Corticosteroid Oral Inhalation Quantity Limit (Exchange Only) Corticosteroid Oral Inhalation Quantity Limit (Exchange Only)
    Corticosteroid Topical Quantity Limit and Post Limit (Exchange Only) Corticosteroid Topical Quantity Limit and Post Limit (Exchange Only)
    Cosentyx® Cosentyx®
    Cotellic® Cotellic®
    Crestor® Crestor®
    Cuvitru® Cuvitru®
    Cymbalta® Cymbalta®
    Cymbalta® Cymbalta®
    Cyramza® Cyramza®
    Cystaran® Cystaran®
    Cytogam® Cytogam®

    D

    Drug Name
    Drug Criteria
    Daklinza® Daklinza®
    Daliresp® (Exchange Only) Daliresp® (Exchange Only)
    Darzalex® Darzalex®
    Delzicol® Delzicol®
    Desvenlafaxine Step Therapy (Exchange Only) Desvenlafaxine Step Therapy (Exchange Only)
    Detrol LA® Detrol LA®
    Dexpak® Dexpak®
    Differin® (Exchange Only) Differin® (Exchange Only)
    Dificid® (Exchange Only) Dificid® (Exchange Only)
    Diabetic Test Strips Quantity Limit Diabetic Test Strips Quantity Limit
    Diabetic Test Strips Post Limit Diabetic Test Strips Post Limit
    Diovan HCT Policy® Diovan HCT Policy®
    Docefrez® Docefrez®
    Dofetilide® Dofetilide®
    DPP-4 Inhibitors (Exchange Only) DPP-4 Inhibitors (Exchange Only)
    DPP-4 Inhibitors Step Therapy (Exchange Only) DPP-4 Inhibitors Step Therapy (Exchange Only)
    Dronabinol Quantity Limit (Exchange Only) Dronabinol Quantity Limit (Exchange Only)
    Dupixent® Dupixent®
    Dutoprol® Dutoprol®
    Dysport® Dysport®
    Dyrenium® Dyrenium®

    E

    Drug Name
    Drug Criteria
    E.E.S. Granules® E.E.S. Granules®
    Edarbi® Edarbi®
    Edarbyclor® Edarbyclor®
    Egrifta® Egrifta®
    Elaprase® Elaprase®
    Eleyso® Eleyso®
    Elidel Step Therapy (Exchange Only) Elidel Step Therapy (Exchange Only)
    Eligard® Eligard®
    Elocate® Elocate®
    Eloxatin® Eloxatin®
    Emflaza® Emflaza®
    Empliciti® Empliciti®
    Emverm® Emverm®
    Enablex® Enablex®
    Enbrel® Enbrel®
    Entesto® Entesto®
    Entyvio® Entyvio®
    Epclusa® Epclusa®
    Epogen® Epogen®
    Epoprostenol® Epoprostenol®
    Erbitux® Erbitux®
    Ergomar Step Therapy (Exchange Only) Ergomar Step Therapy (Exchange Only)
    Erleada® Erleada®
    Erivedge® Erivedge®
    Erwinaze® Erwinaze®
    Eryped® Erypedx®
    Esbriet® Esbriet®
    Evzio® Evzio®
    Exelon Policy (Exchange Only) Exelon Policy (Exchange Only)
    Exflexxa Policy® Exflexxa Policy®
    Exforge® Exforge®
    Exforge HCT® Exforge HCT®
    Exjade® Exjade®
    Exondys 51® Exondys 51®
    Extavia® Extavia®
    Eylea® Eylea®

    F

    Drug Name
    Drug Criteria
    Fabior® Fabior®
    Fanrazyme® Fanrazyme®
    Farydak® Farydak®
    Fasenra® Fasenra®
    Feiba NF® Feiba NF®
    Feiba VH® Feiba VH®
    Fentanyl Citrate Oral TRA® Fentanyl Citrate Oral TRA®
    Fentora® Fentora®
    Ferriprox® Ferriprox®
    Fioricet Capsule® Fioricet Capsule®
    Firazyr® Firazyr®
    Firmagon® Firmagon®
    Flebogamma DIF® Flebogamma DIF ®
    Flolan® Flolan®
    Fluorouracil Cream 0.5%® Fluorouracil Cream 0.5%®
    Follistim AQ® Follistim AQ®
    Fortamet® Fortamet®
    Forteo® Forteo®
    Fortesta® Fortesta®
    Fosrenol® Fosrenol®
    Freestyle Test Strips® Freestyle Test Strips®
    Frova Post Limit® Frova Post Limit®
    Fuzeon® Fuzeon®

    G

    Drug Name
    Drug Criteria
    Gamastan S/D® Gamastan S/D®
    Gammagard S/D Less 1g® Gammagard S/D Less 1g®
    Gammaked® Gammaked®
    Gammaplex® Gammaplex®
    Gamunex-C® Gamunex-C®
    Ganirelix Acetate® Ganirelix Acetate®
    Gattex® Gattex®
    Gazyva® Gazyva®
    Gel-One® Gel-One®
    Gelnique® Gelnique®
    Gemzar® Gemzar®
    Genotropin® Genotropin®
    Gilenya® Gilenya®
    Gilotrif® Gilotrif®
    Glassia® Glassia®
    Glatopa® Glatopa®
    Gleevec® Gleevec®
    Glumetza® Glumetza®
    Gonal-F® Gonal-F®
    Granix® Granix®

    H

    Drug Name
    Drug Criteria
    Halaven® Halaven®
    Harvoni® Harvoni®
    Haegarda® Haegarda®
    Hecoria® Hecoria®
    Helixate FS® Helixate FS®
    Hemlibra® Hemlibra®
    Hemofil M® Hemofil M®
    Herceptin® Herceptin®
    Hetlioz® Hetlioz®
    High Risk Medications (Exchange Only) High Risk Medications (Exchange Only)
    Hizentra® Hizentra®
    Humalog® Humalog®
    Humalog Mix 50/60® Humalog Mix 50/60®
    Humalog Mix 75/25® Humalog Mix 75/25®
    Humate-P® Humate-P®
    Humatrope® Humatrope®
    Humira® Humira®
    Humulin 70/30 2® Humulin 70/30®
    Humulin N 2® Humulin N 2®
    Humulin R 2® HUmulin R 2®
    Hyalgan® Hyalgan®
    Hycamtin® Hycamtin®
    Hymovis® Hymovis® Policy
    HyQvia® HyQvia® Policy

    I

    Drug Name
    Drug Criteria
    Ibrance® Ibrance®
    Iclusig® Iclusig®
    Idelvion® Idelvion®
    Idhifa® Idhifa®
    Ilaris® Ilaris®
    Imbruvica® Imbruvica®
    Imfinzi® Imfinzi®
    Increlex® Increlex®
    Incruse Ellipta® Incruse Ellipta®
    Inflectra® Inflectra® Policy
    Influenza Treatment Post QL PA® Influenza Treatment Post QL PA®
    Inlyta® Inlyta®
    Ingrezza® Ingrezza®
    Insomnia Quantity Limit (Exchange Only) Insomnia Quantity Limit (Exchange Only)
    Intermezzo® Intermezzo®
    Intron A® Intron A®
    Intuniv® Intuniv®
    Intuniv-Kapvay Step Therapy (Exchange Only) Intuniv-Kapvay Step Therapy (Exchange Only)
    Invokamet® Invokamet®
    Invokana® Invokana®
    Iressa® Iressa®
    Isotretinoins® (Exchange Only) Isotretinoins® (Exchange Only)
    Itraconazole (Sporanox) Capsules® (Exchange Only) Itraconazole (Sporanox) Capsules® (Exchange Only)
    Itraconazole (Sporanox) Solution® (Exchange Only) Itraconazole (Sporanox) Solution® (Exchange Only)
    Ixinity® Ixinity®

    J

    Drug Name
    Drug Criteria
    Jadenu® Jadenu®
    Jakafi® Jakafi®
    Jalyn® Jalyn®
    Jevtana® Jevtana®
    Juxtapid® Juxtapid®

    K

    Drug Name
    Drug Criteria
    Kadcyla® Kadcyla®
    Kalbitor® Kalbitor®
    Kalydeco® Kalydeco®
    Kanuma® Kanuma®
    Kazano® Kazano®
    Ketorolac Quantity Limit (Exchange Only) Ketorolac Quantity Limit (Exchange Only)
    Kevzara® Kevzara®
    Keytruda® Keytruda®
    Kineret® Kineret®
    Kisqali® Kisqali®
    Kisqali Femara Co-Pack® Kisqali Femara Co-Pack®
    Kitabis PAK® Kitabis PAK®
    Klor-Con/25® Klor-Con/25®
    Koate-DVI® Koate-DVI®
    Kogenate FS® Kogenate FS®
    Kombiglyze XR® Kombiglyze XR®
    Korlym® Korlym®
    Krystexxa® Krystexxa®
    Kuvan® Kuvan®
    Kymriah® Kymriah®
    Kynamro® Kynamro®
    Kyprolis® Kyprolis®

    L

    Drug Name
    Drug Criteria
    Lamisil® Oral Granules (Exchange Only) Lamisil® Oral Granules (Exchange Only)
    Lamisil® Tablets (Exchange Only) Lamisil® Tablets (Exchange Only)
    Lanoxin Tablet (125 MCG and 250 MCG only)® Lanoxin Tablet (125 MCG and 250 MCG only)®
    Lantus® Lantus®
    Lastacaft® Lastacaft®
    Lazanda® Lazanda®
    Lemtrada® Lemtrada®
    Lenvima® Lenvima®
    Lescol XL® Lescol XL®
    Letairis® Letairis®
    Leukine® Leukine®
    Leuprolide Acetate® Leuprolide Acetate®
    Levitra® Levitra®
    Lidocaine® Lidocaine®
    Lipitor® Lipitor®
    Liptruzet® Liptruzet®
    Livalo® Livalo®
    Lonsurf® Lonsurf®
    Lotronex® (Exchange Only) Lotronex® (Exchange Only)
    Lovaza® Lovaza®
    Lucentis® Lucentis®
    Lumigan® Lumigan®
    Lumizyme® Lumizyme®
    Lunesta® Lunesta®
    Lupron Depot® Lupron Depot®
    Lupron Depot-PED® Lupron Depot-PED®
    Lupron Depot - Prostate Cancer® Lupron Depot - Prostate Cancer®
    Lynparaza® Lynparaza®
    Lyrica, Gralise, Horizant Step Therapy (Exchange Only) Lyrica, Gralise, Horizant Step Therapy (Exchange Only)

    M

    Drug Name
    Drug Criteria
    Macrodantin® Macrodantin®
    Macugen® Macugen®
    Makena® Makena®
    Matzim LA® Matzim LA®
    Mavyret® Mavyret®
    Mekinist® Mekinist®
    Menopur® Menopur®
    Methadone (oral Concentrate, Dispersible Tablets) Quantity Limit (Exchange Only) Methadone (oral Concentrate, Dispersible Tablets) Quantity Limit (Exchange Only)
    Miacalcin Injection® Miacalcin Injection®
    Miacalcin Nasal Spray® Miacalcin Nasal Spray®
    Millipred® Millipred®
    Mircera® Mircera®
    Moderiba® Moderiba®
    Monoclate-P® Monoclate-P®
    Mononine® Mononine®
    Monovisc® Monovisc®
    Myalept® Myalept®
    Myobloc® Myobloc®
    Myozyme® Myozyme®

    N

    Drug Name
    Drug Criteria
    Naglazyme® Naglazyme®
    Nail Antifungal Topical Aligned (Exchange Only) Nail Antifungal Topical Aligned (Exchange Only)
    Namenda® (Exchange Only) Namenda® (Exchange Only)
    Natesto® Natesto®
    Natpara® Natpara®
    Nesina® Nesina®
    Nerlynx® Nerlynx®
    Neulasta® Neulasta®
    Neupogen® Neupogen®
    Nexavar® Nexavar®
    Nexium® Nexium®
    Nilandron® Nilandron®
    Ninlaro® Ninlaro®
    Nityr® Nityr®
    Norditropin Flexpro® Norditropin Flexpro®
    Noritate® Noritate®
    Northera® Northera®
    Norvasc® Norvasc®
    Novacort® Novacort®
    Novo Nordisk Needle® Novo Nordisk Needle®
    Novoseven® Novoseven®
    Nplate® Nplate®
    Nucala® Nucala®
    Nuplazid® Nuplazid®
    Nutropin AQ® Nutropin AQ®

    O

    Drug Name
    Drug Criteria
    Obizur® Obizur®
    Ocaliva® Ocaliva®
    Octagam® Octagam®
    Ocrevus® Ocrevus®
    Octreotide Acetate® Octreotide Acetate®
    Odomzo® Odomzo®
    Ofev® Ofev®
    Oleptro® Oleptro®
    Olux-E® Olux-E®
    Olysio® Olysio®
    Omega-3-Acid Ethyl Esters® Omega-3-Acid Ethyl Esters®
    Omega-3 Fatty Acids® (Exchange Only) Omega-3 Fatty Acids® (Exchange Only)
    Omnaris® Omnaris®
    Omnitrope® Omnitrope®
    Oncaspar® Oncaspar®
    Onfi® (Exchange Only) Onfi® (Exchange Only)
    Onglyza® Onglyza®
    Onsolis® Onsolis®
    Opdivo® Opdivo®
    Opioids ER MME Limit and Post Limit Opioids ER MME Limit and Post Limit
    Opioids ER - Step Therapy with MME Quantiy Limit and Post Limit (Exchange Only) Opioids ER - Step Therapy with MME Quantiy Limit and Post Limit (Exchange Only)
    Opioids IR MME Limit and Post Limit Opioids IR MME Limit and Post Limit
    Opioids IR APAP ASA IBU Limit® Opioids IR APAP ASA IBU Limit®
    Opsumit® Opsumit®
    Oral Pain Meds Post QL® Oral Pain Meds Post QL®
    Orencia IV® Orencia IV Policy®
    Orencia SQ® Orencia SQ Policy®
    Orenitram® Orenitram®
    Orfadin® Orfadin®
    Orkambi® Orkambi®
    Orthovisc® Orthovisc®
    Oseni® Oseni®
    Otezla® Otezla®
    Otrexup® Otrexup®
    Ovidrel® Ovidrel®
    Owen Mumford Needles® Owen Mumford Needles®
    Oxytrol® Oxytrol®

    P

    Drug NameDrug Criteria
    Pegasys® Pegasys®
    Pennsaid® Pennsaid®
    Perjeta® Perjeta®
    Perrigo Needles® Perrigo Needles®
    Plavix® Plavix®
    Plegridy® Plegridy®
    Pomalyst® Pomalyst®
    Pradaxa® Pradaxa®
    Praluent® Praluent®
    Pregnyl® Pregnyl®
    Prevacid® Prevacid®
    Privigen® Privigen®
    Procrit® Procrit®
    Procysbi® Procysbi®
    Profilnine SD® Profilnine SD®
    Prolastin-C® Prolastin-C®
    Prolia® Prolia®
    Promacta® Promacta®
    Proton Pump Inhibitors Quantity Limit (Exchange Only) Proton Pump Inhibitors Quantity Limit (Exchange Only)
    Protonix® Protonix®
    Protopic Step Therapy (Exchange Only) Protopic Step Therapy (Exchange Only)
    Provenge® Provenge®
    Proventil HFA® Proventil HFA®
    Prudoxin®, Zonalon® (Step Therapy) Prudoxin®, Zonalon® (Step Therapy)
    Pulmozyme® Pulmozyme®

    Q

    Drug Name
    Drug Criteria
    QNSL® QNSL®
    Qsymia® Qsymia®

    R

    Drug Name
    Drug Criteria
    Radicava® Radicava®
    Ranexa Step Therapy (Exchange Only) Ranexa Step Therapy (Exchange Only)
    Rasuvo® Rasuvo®
    Ravicti® Ravicti®
    Rayos® Rayos®
    Rebetol® Rebetol®
    Rebif® Rebif®
    Rebinyn® Rebinyn®
    Reclast® Reclast®
    Recombinate® Recombinate®
    Regranex® Regranex®
    Relistor® Relistor®
    Remicade® Remicade®
    Remoulin® Remoulin®
    Renflexis® Renflexis®
    Repatha® Post Limit Repatha® Post Limit Policy
    Replax® Post Limit Replax® Post Limit
    Repronex® Repronex®
    Retin-A® Retin-A®
    Revatio® Revatio®
    Revlimid® Revlimid®
    Rhinocort Aquia® Rhinocort Aquia®
    Riastap® Riastap®
    Ribashpere® Ribashpere®
    Ribavirn® Ribavirn®
    Riomet® Riomet®
    Rituxan® Rituxan®
    Rituxan® - Oncology Rituxan® - Oncology
    Rixubis® Rixubis®
    Rozerem® Rozerem®
    Rubraca® Rubraca®
    Ruconest® Ruconest®
    Rydapt® Rydapt®

    S

    Drug Name
    Drug Criteria
    Sabril® Sabril®
    Saizen® Saizen®
    Samsca® Samsca®
    Sandostatin® Sandostatin®
    Sandostatin Lar Depot® Sandostatin Lar Depot®
    Senispar® Senispar®
    Serostim® Serostim®
    Signifor LAR® Signifor LAR®
    Sildenafil® Sildenafil®
    Siliq® Siliq®
    Simponi® Simponi Policy®
    Simponi Aria® Simponi Aria Policy®
    Sodium Phenylbutyrate® Sodium Phenylbutyrate®
    Solaraze® Solaraze®
    Soliris® Soliris®
    Solodyn(Step Therapy)® Solodyn(Step Therapy)®
    Solodyn Step Therapy (Brand Only)® Solodyn Step Therapy (Brand Only)®
    Somatuline Depot® Somatuline Depot®
    Somavert® Somavert®
    Sovaldi® Sovaldi®
    Spinraza® Spinraza®
    Sprycel® Sprycel®
    Stelara IV® Stelara® IV Policy
    Stelara® SQ Stelara® SQ Policy
    Stivarga® Stivarga®
    Strensiq® Strensiq®
    Subsys® Subsys®
    Supartz® Supartz®
    Supprelin LA® Supprelin LA®
    Sutent® Sutent®
    Sylatron® Sylatron®
    Symbicort® Symbicort®
    Symdeko® Symdeko®
    Symlin® (Exchange Only) Symlin® (Exchange Only)
    Synagis® Synagis®
    Synvisc®, Synvisc One® Synvisc®, Synvisc One®

    T

    Drug Name
    Drug Criteria
    Taflinar® Taflinar®
    Tagrisso® Tagrisso®
    Taltz® Taltz®
    Tarceva® Tarceva®
    Targretin® Targretin®
    Tasigna® Tasigna®
    Taxotere® Taxotere®
    Tazorac® Tazorac®
    Tazorac® (Exchange Only) Tazorac® (Exchange Only)
    Tecentriq® Tecentriq®
    Tecfidera® Tecfidera®
    Technivie® Technivie®
    Temodar® Temodar®
    Temozolomide® Temozolomide®
    Test Strips(Non-One Touch Brands)® Test Strips(Non-One Touch Brands)®
    Testim® Testim®
    Testosterone Gel 1% 5® Testosterone Gel 1% 5®
    Testosterone - Oral Non-TGC® (Exchange Only) Testosterone - Oral Non-TGC® (Exchange Only)®
    Testosterone Products TGC® (Exchange Only) Testosterone Products TGC®® (Exchange Only)®
    Tetrabenazine® Tetrabenazine®
    Teveten® Teveten®
    Teveten HCT® Teveten HCT®
    Tev-Tropin® Tev-Tropin®
    Thalomid® Thalomid®
    Tikosyn® Tikosyn®
    Tobi® Tobi®
    Tobramycin® Tobramycin®
    Toujeo® Toujeo®
    Tracleer® Tracleer®
    Treanda® Treanda®
    Trelstar® Trelstar®
    Tremfya® Tremfya®
    Tretinoin Products® Tretinoin Products®
    Tretin-X® Tretin-X®
    Tretten® Tretten®
    Treximet Post Limit® Treximet Post Limit®
    Tricor® Tricor®
    Tricyclic Antidepressant® (TCA) Agents (Elderly) Quantity Limit (Exchange Only) Tricyclic Antidepressant (TCA) Agents (Elderly) Quantity Limit (Exchange Only)
    Triptodur® Triptodur®
    Trividia Insulin Syringes® Trividia Insulin Syringes®
    Tudorza® Tudorza®
    Tykerb® Tykerb®
    Tymlos® Tymlos®
    Tysabri® Tysabri®
    Tyvaso Starter® Tyvaso Starter®

    U

    Drug NameDrug Criteria
    Ultimed Insulin Syringes® Ultimed Insulin Syringes®
    Ultimed Needles® Ultimed Needles®
    Uloric step Therapy (Exchange Only) Uloric step Therapy (Exchange Only)
    Uptravi® Uptravi®
    Uroxatral® Uroxatral®

    V

    Drug Name
    Drug Criteria
    Valchlor® Valchlor®
    Valcyte® Valcyte®
    Valtrex® Valtrex®
    Vancocin capsule Step Therapy (Exchange Only) Vancocin capsule Step Therapy (Exchange Only)
    Vanocide-HC® Vanocide-HC®
    Vantas® Vantas®
    Vascepa® Vascepa®
    Vectibix® Vectibix®
    Velcade® Velcade®
    Veletri® Veletri®
    Venclexta® Venclexta®
    Venlafaxine ext-rel tablets (except for 225 mg)® venlafaxine ext-rel tablets (except for 225 mg)®
    Ventavis® Ventavis®
    Ventolin HFA® Ventolin HFA®
    Veramyst® Veramyst®
    Vfend Policy® (Exchange Only) Vfend Policy® (Exchange Only)
    Viagra® Viagra®
    Vidaza® Vidaza®
    Viekira PAK® Viekira PAK®
    Vimizim® Vimizim®
    Visco-3® Visco-3®
    Visudyne® Visudyne®
    Vogelxo® Vogelxo®
    Voltaren® Gel Quantity Limit (Exchange Only) Voltaren® Gel Quantity Limit (Exchange Only)
    Vonvendi® Vonvendi®
    Votrient® Votrient®
    Vosevi® Vosevi®
    VPRIV® VPRIV®
    Vytorin 10-80 Zocor 80 Step Therapy (Exchange Only) Vytorin 10-80 Zocor 80 Step Therapy (Exchange Only)

    W

    Drug NameDrug Criteria
    Wilate® Wilate®

    X

    Drug Name
    Drug Criteria
    Xalkori® Xalkori®
    Xartemis® XR MME Limit Xartemis® XR MME Limit
    Xeljanz® Xeljanz®
    Xeloda® Xeloda®
    Xenazine® Xenazine®
    Xeomin® Xeomin®
    Xermelo® Xermelo®
    Xgeva® Xgeva®
    Xifaxan® Xifaxan®
    Xifaxin® 550mg (Exchange Only) Xifaxin® 550mg (Exchange Only)®
    Xolair® Xolair®
    Xopenex HFA® Xopenex® HFA Policy
    Xtandi® Xtandi®
    Xyntha® Xyntha®

    Y

    Drug Name
    Drug Criteria
    Yescarta® Yescarta®
    Yervoy® Yervoy®

    Z

    Drug Name
    Drug Criteria
    Zarxio® Zarxio®
    Zavesca® Zavesca®
    Zegerid® Zegerid®
    Zejula® Zejula®
    Zelboraf® Zelboraf®
    Zemaira® Zemaira®
    Zepatier® Zepatier®
    Zetonna® Zetonna®
    Zinbryta® Zinbryta®
    Zofran-Zuplenz® Quantity Limit (Exchange Only) Zofran-Zuplenz® Quantity Limit (Exchange Only)
    Zoladex® Zoladex®
    Zoledronic Acid® Zoledronic Acid®
    Zolinza® Zolinza®
    Zomacton® Zomacton®
    Zometa® Zometa®
    Zonegran® Zonegran®
    Zorbtive® Zorbtive®
    Zubsolv® Zubsolv®
    Zydelig® Zydelig®
    Zykadia® Zykadia®
    Zytiga® Zytiga®