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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

Jump To:

#

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

A

Drug Name
Drug Criteria
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
Adagen® Adagen® Policy
ADHD Agents Post Limit (Exchange Only) Adagen® ADHD Agents Post Limit (Exchange Only)
Adcetris ® Adcetris ® Policy
Adcirca® Adcirca® Policy
Adempas® Adempas® Policy
ADHD Agents Post Limit ADHD Agents Post Limit
Advate® Advate® Policy
Afinitor® Afinitor® Policy
Afstyla ® Afstyla® Policy
Akynzeo® Quantity Limit Akynzeo® Quantity Limit
Akynzeo® Post Limit (Exchange Only) Akynzeo® Post Limit (Exchange Only)
Albenza® Albenza® Policy
Aldurazyme® Aldurazyme® Policy
Alecensa® Alecensa® Policy
Alferon® Alferon® Policy
Alimta® Alimta® Policy
Alphanate® Alphanate® Policy
Alphanine SD® Alphanine SD® Policy
Alprolix® Alprolix® Policy
Alsuma® Alsuma® Policy
Alunbrig® Alunbrig®
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)®
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)
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)
Anzemet Quantity Limit® Anzemet Quantity Limit®
Apokyn® Apokyn® Policy
Aptiom (Exchange Only)® Aptiom (Exchange Only)® Policy
Aralast NP® Aralast NP® Policy
Aranesp® Aranesp® Policy
Arcalyst® Arcalyst® Policy
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®
Bendeka® Bendeka®
Benefix® Benefix®
Benlysta® Benlysta®
Berinert® Berinert®
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®
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)
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)
Butorphanol Nasal Solution (Stadol) Butorphanol Nasal Solution (Stadol)
Butorphanol Nasal Solution (Stadol) Quantity Limit (Exchange Only) Butorphanol Nasal Solution (Stadol) Quantity Limit (Exchange Only)

C

Drug NameDrug Criteria
Cabometyx® Cabometyx®
Capecitabine® Capecitabine®
Caprelsa® Caprelsa®
Carbaglu® Carbaglu®
Carimune NF® Carimune NF®
Cayston® Cayston®
Cesamet® Quantity Limit (Exchange Only) Cesamet® Quantity Limit (Exchange Only)
Cesamet® Post Limit (Exchange Only) Cesamet® Post 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®
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®
Cuvitru® Cuvitru®
Cyramza® Cyramza®
Cystaran® Cystaran®
Cytogam® Cytogam®

D

Drug Name
Drug Criteria
Daklinza® Daklinza®
Daliresp® (Exchange Only) Daliresp® (Exchange Only)
Darzalex® Darzalex®
Desvenlafaxine Step Therapy (Exchange Only) Desvenlafaxine Step Therapy (Exchange Only)
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
Dificid® (Exchange Only) Dificid® (Exchange Only)
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)
Dronabinol® Post Limit (Exchange Only) Dronabinol® Post Limit (Exchange Only)
Dupixent® Dupixent®
Durolane® Durolane®
Dysport® Dysport®

E

Drug Name
Drug Criteria
Egrifta® Egrifta®
Elaprase® Elaprase®
Eleyso® Eleyso®
Elidel Step Therapy (Exchange Only) Elidel Step Therapy (Exchange Only)
Eligard® Eligard®
Elocate® Elocate®
Eloxatin® Eloxatin®
Emend®, Cinvanti® Varubi Quantity Limit Emend®, Cinvanti® Varubi Quantity Limit
Emend®, Cinvanti® Post Limit (Exchange Only) Emend®, Cinvanti® Post Limit (Exchange Only)
Emflaza® Emflaza®
Empliciti® Empliciti®
Emverm® Emverm®
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®
Esbriet® Esbriet®
Euflexxa® Euflexxa®
Exelon Policy (Exchange Only) Exelon Policy (Exchange Only)
Exflexxa Policy® Exflexxa Policy®
Exjade® Exjade®
Exondys 51® Exondys 51®
Extavia® Extavia®
Eylea® Eylea®

F

Drug Name
Drug Criteria
Fabior® Fabior®
Farydak® Farydak®
Fasenra® Fasenra®
Feiba NF® Feiba NF®
Feiba VH® Feiba VH®
Fentanyl Citrate Oral TRA® Fentanyl Citrate Oral TRA®
Fentora® Fentora®
Ferriprox® Ferriprox®
Firazyr® Firazyr®
Firmagon® Firmagon®
Flebogamma DIF® Flebogamma DIF ®
Flolan® Flolan®
Follistim AQ® Follistim AQ®
Fortamet® Fortamet®
Forteo® Forteo®
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®
Gelsyn-3® Gelsyn-3®
Gemzar® Gemzar®
Genotropin® (Exchange and Medical Only) Genotropin® (Exchange and Medical Only)
Genvisc 850® Genvisc 850®
Gilenya® Gilenya®
Gilotrif® Gilotrif®
Glassia® Glassia®
Glatopa® Glatopa®
Gleevec® Gleevec®
Glumetza® Glumetza®
Gonal-F® Gonal-F®
Granisetron-Sancuso-Sustol® Limit Granisetron-Sancuso-Sustol® Limit
Granix® Granix®

H

Drug Name
Drug Criteria
Halaven® Halaven®
Harvoni® Harvoni®
Haegarda® Haegarda®
Helixate FS® Helixate FS®
Hemlibra® Hemlibra®
Hemofil M® Hemofil M®
Herceptin® Herceptin®
Hetlioz® Hetlioz®
High Risk Medications (HRM Long List) (Exchange Only) High Risk Medications (HRM Long List) (Exchange Only)
Hizentra® Hizentra®
Humate-P® Humate-P®
Humatrope® (Exchange and Medical Only) Humatrope® (Exchange and Medical Only)
Humira® Humira®
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®
Inflectra® Inflectra® Policy
Influenza Treatment Post QL PA® Influenza Treatment Post QL PA®
Influenza Treatment and Prevention Quantity Limit Influenza Treatment and Prevention Quantity Limit
Influenza Treatment and Prevention Post Limit Influenza Treatment and Prevention Post Limit
Influenza Treatment and Prevention Post Limit (Exchange Only) Influenza Treatment and Prevention Post Limit (Exchange Only)
Inlyta® Inlyta®
Ingrezza® Ingrezza®
Insomnia Quantity Limit (Exchange Only) Insomnia Quantity Limit (Exchange Only)
Intron A® Intron A®
Intuniv-Kapvay Step Therapy (Exchange Only) Intuniv-Kapvay Step Therapy (Exchange Only)
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®
Jevtana® Jevtana®
Juxtapid® Juxtapid®

K

Drug Name
Drug Criteria
Kadcyla® Kadcyla®
Kalbitor® Kalbitor®
Kalydeco® Kalydeco®
Kanuma® Kanuma®
Ketorolac Quantity Limit (Exchange Only) Ketorolac Quantity Limit (Exchange Only)
Keveyis® Keveyis®
Kevzara® Kevzara®
Keytruda® Keytruda®
Kineret® Kineret®
Kisqali® Kisqali®
Kisqali Femara Co-Pack® Kisqali Femara Co-Pack®
Kitabis PAK® Kitabis PAK®
Koate® Koate®
Kogenate FS® Kogenate FS®
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)
Lazanda® Lazanda®
Lemtrada® Lemtrada®
Lenvima® Lenvima®
Letairis® Letairis®
Leukine® Leukine®
Leuprolide Acetate® Leuprolide Acetate®
Lidocaine® Lidocaine®
Lidocaine® Topical Lidocaine-Prilocaine® Lidocaine-Tetracaine® Quantity Limit Lidocaine® Topical Lidocaine-Prilocaine® Lidocaine-Tetracaine® Quantity Limit
Lidocaine Topical Lidocaine-Prilocaine Lidocaine-Tetracaine Post Limit (Exchange Only) Lidocaine Topical Lidocaine-Prilocaine Lidocaine-Tetracaine Post Limit (Exchange Only)
Lidoderm® Lidoderm®
Lonsurf® Lonsurf®
Lotronex® (Exchange Only) Lotronex® (Exchange Only)
Lovaza® Lovaza®
Lucentis® Lucentis®
Lumizyme® Lumizyme®
Lupron Depot® Lupron Depot®
Lupron Depot-PED® Lupron Depot-PED®
Lupron Depot - Prostate Cancer® Lupron Depot - Prostate Cancer®
Luxturna® Luxturna®
Lynparaza® Lynparaza®
Lyrica, Gralise, Horizant Step Therapy (Exchange Only) Lyrica, Gralise, Horizant Step Therapy (Exchange Only)

M

Drug Name
Drug Criteria
Macugen® Macugen®
Makena® Makena®
Mavyret® Mavyret®
Mekinist® Mekinist®
Menopur® Menopur®
Methadone (oral Concentrate, Dispersible Tablets) Quantity Limit (Exchange Only) Methadone (oral Concentrate, Dispersible Tablets) Quantity Limit (Exchange Only)
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)
Natpara® Natpara®
Nerlynx® Nerlynx®
Neulasta® Neulasta®
Neupogen® Neupogen®
Nexavar® Nexavar®
Ninlaro® Ninlaro®
Nityr® Nityr®
Norditropin® (Exchange and Medical Only) Norditropin® (Exchange and Medical Only)
Northera® Northera®
Novoseven® Novoseven®
Novoeight® Novoeight®
Nplate® Nplate®
Nucala® Nucala®
Nuplazid® Nuplazid®
Nutropin AQ®(Exchange and Medical Only) Nutropin AQ®(Exchange and Medical Only)
Nuwiq® Nuwiq®

O

Drug Name
Drug Criteria
Obizur® Obizur®
Ocaliva® Ocaliva®
Octagam® Octagam®
Ocrevus® Ocrevus®
Octreotide Acetate® Octreotide Acetate®
Odomzo® Odomzo®
Ofev® Ofev®
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®  (Exchange and Medical Only) Omnitrope® (Exchange and Medical Only)
Oncaspar® Oncaspar®
Onfi® (Exchange Only) Onfi® (Exchange Only)
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
Opiods IR - Acute Pain Duration Limit with MME Quantity Limit and Post Limit Opiods IR - Acute Pain Duration Limit with MME Quantity Limit and Post Limit
Opioids IR APAP-ASA-IBU – Combo Products – Acute Pain Duration Quantity Limit Opioids IR APAP-ASA-IBU – Combo Products – Acute Pain Duration Quantity Limit
Opsumit® Opsumit®
Oral Pain Meds Post QL® Oral Pain Meds Post QL®
Oral-Intranasal® Fentanyl Products Oral-Intranasal® Fentanyl Products
Orencia IV® Orencia IV Policy®
Orencia SQ® Orencia SQ Policy®
Orenitram® Orenitram®
Orfadin® Orfadin®
Orkambi® Orkambi®
Orthovisc® Orthovisc®
Otezla® Otezla®
Otrexup® Otrexup®
Ovidrel® Ovidrel®

P

Drug NameDrug Criteria
Pegasys® Pegasys®
Pennsaid® Pennsaid®
Perjeta® Perjeta®
Plegridy® Plegridy®
Pomalyst® Pomalyst®
Praluent® (Formulary 1 and Exchange) Praluent® (Formulary 1 and Exchange)
Praluent® (Formulary 2 and 3) Praluent® (Formulary 2 and 3)
Pregnyl® Pregnyl®
Privigen® Privigen®
Procrit® Procrit®
Procysbi® Procysbi®
Profilnine SD® Profilnine SD®
Prolastin-C® Prolastin-C®
Prolia® Prolia®
Promacta® Promacta®
Proton Pump Inhibitors Post Limit (Exchange Only) Proton Pump Inhibitors Post Limit (Exchange Only)
Proton Pump Inhibitors Quantity Limit (Exchange Only) Proton Pump Inhibitors Quantity Limit (Exchange Only)
Protopic Step Therapy (Exchange Only) Protopic Step Therapy (Exchange Only)
Provenge® Provenge®
Prudoxin®, Zonalon® (Step Therapy) Prudoxin®, Zonalon® (Step Therapy)
Pulmozyme® Pulmozyme®

R

Drug Name
Drug Criteria
Radicava® Radicava®
Ranexa Step Therapy (Exchange Only) Ranexa Step Therapy (Exchange Only)
Rasuvo® Rasuvo®
Ravicti® Ravicti®
Rebetol® Rebetol®
Rebif® Rebif®
Rebinyn® Rebinyn®
Reclast® Reclast®
Recombinate® Recombinate®
Regranex® Regranex®
Remicade® Remicade®
Remodulin® Remodulin®
Renflexis® Renflexis®
Repatha® (Formulary 1 and Exchange) Repatha® (Formulary 1 and Exchange)
Repatha® (Formulary 2 and 3) Repatha® (Formulary 2 and 3)
Replax® Post Limit Replax® Post Limit
Repronex® Repronex®
Retin-A® Retin-A®
Revatio® Revatio®
Revlimid® Revlimid®
Riastap® Riastap®
Ribashpere® Ribashpere®
Ribavirn® Ribavirn®
Rituxan® Rituxan®
Rituxan® - Oncology Rituxan® - Oncology
Rixubis® Rixubis®
Rubraca® Rubraca®
Ruconest® Ruconest®
Rydapt® Rydapt®

S

Drug Name
Drug Criteria
Sabril® Sabril®
Saizen® (Exchange and Medical Only) Saizen® (Exchange and Medical Only)
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®
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®
Tavalisse® Tavalisse®
Taxotere® Taxotere®
Tazorac® Tazorac®
Tazorac® (Exchange Only) Tazorac® (Exchange Only)
Tecentriq® Tecentriq®
Tecfidera® Tecfidera®
Technivie® Technivie®
Temodar® Temodar®
Temozolomide® Temozolomide®
Testosterone - Oral Non-TGC® (Exchange Only) Testosterone - Oral Non-TGC® (Exchange Only)®
Testosterone Products TGC® (Exchange Only) Testosterone Products TGC®® (Exchange Only)®
Tetrabenazine® Tetrabenazine®
Thalomid® Thalomid®
Tikosyn® Tikosyn®
Tobi® Tobi®
Tobramycin® Tobramycin®
Tracleer® Tracleer®
Treanda® Treanda®
Trelstar® Trelstar®
Tremfya® Tremfya®
Tretinoin Products® Tretinoin Products®
Tretin-X® Tretin-X®
Tretten® Tretten®
Treximet Post Limit® Treximet Post Limit®
Tricyclic Antidepressant (TCA) Agents (Elderly) Post Limit (Exchange Only) Tricyclic Antidepressant (TCA) Agents (Elderly) Post Limit (Exchange Only)
Tricyclic Antidepressant® (TCA) Agents (Elderly) Quantity Limit (Exchange Only) Tricyclic Antidepressant (TCA) Agents (Elderly) Quantity Limit (Exchange Only)
Triptodur® Triptodur®
Tykerb® Tykerb®
Tymlos® Tymlos®
Tysabri® Tysabri®
Tyvaso Starter® Tyvaso Starter®

U

Drug NameDrug Criteria
Uloric step Therapy (Exchange Only) Uloric step Therapy (Exchange Only)
Uptravi® Uptravi®

V

Drug Name
Drug Criteria
Valchlor® Valchlor®
Vancocin capsule Step Therapy (Exchange Only) Vancocin capsule Step Therapy (Exchange Only)
Vancomycin® Oral Step Therapy (Exchange Only) Vancomycin® Oral Step Therapy (Exchange Only)
Vantas® Vantas®
Vascepa® Vascepa®
Vectibix® Vectibix®
Velcade® Velcade®
Veletri® Veletri®
Venclexta® Venclexta®
Ventavis® Ventavis®
Vfend Policy® (Exchange Only) Vfend Policy® (Exchange Only)
Vidaza® Vidaza®
Viekira PAK® Viekira PAK®
Vimizim® Vimizim®
Visco-3® Visco-3®
Visudyne® Visudyne®
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
Xartemis XR MME Quantity Limit Xartemis XR MME Quantity 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®
Xtandi® Xtandi®
Xyntha® Xyntha®
Xyrem® Xyrem®

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®
Zinbryta® Zinbryta®
Zofran-Zuplenz® Quantity Limit Zofran-Zuplenz® Quantity Limit
Zoladex® Zoladex®
Zoledronic Acid® Zoledronic Acid®
Zolinza® Zolinza®
Zomacton® (Exchange and Medical Only) Zomacton® (Exchange and Medical Only)
Zometa® Zometa®
Zorbtive® Zorbtive®
Zydelig® Zydelig®
Zykadia® Zykadia®
Zytiga® Zytiga®