Employer Sponsored Plans with Customized Formulary

Other Forms and Resources

• 2020 Formulary effective July 1 2020
• Preventive Care Medications effective July 1 2020
• Mail Order Pharmacy Form

Prior Authorization Guidelines

• Accolate Zyflo and Zyflo CR
• Actemra RX Policy
• Adagen RX Policy
• Adcetris RX Policy
• Adcirca and Revatio
• Addyi
• Adempas
• ADHD Agents Quantity Limit
• Afinitor and Afinitor Disperz
• Afrezza
• Aldurazyme RX Policy
• Allergen Specific Immunotherapy
• Alpha1 Proteinase Inhibitors Rx Policy
• Amevive RX Policy
• Ampyra
• Anabolic Steroids
• Angiotensin II Receptor Blockers
• Anti Obesity
• Antidepressant Step Therapy
• Antiemetics Quantity Limit
• Antifungals
• Antispasmodics Step Therapy
• Apokyn Rx Policy
• Arcalyst
• Arzerra Rx Policy
• Atypical Antipsychotics Step Therapy
• Aubagio
• Avonex Copaxone Extavia and Betaseron Rx Policy
• Benlysta RX Policy
• Bisphosphonate ST RX Policy
• Boniva
• Bosulif
• Botulinum Toxin
• Butrans
• Cannabinoids
• Caprelsa
• Carbaglu
• Celebrex
• Cerdelga
• Cerezyme Elelyso and Vipriv Rx Policy
• Chelation Therapy
• Cholbam
• Cialis
• Cimzia RX Policy
• Clotting Factor Replacement
• Colony Stimulating Factors RX Policy
• Cometriq
• Compounded Drugs Rx Policy
• Corlanor
• Cosentyx RX Policy
• Cresemba
• Cystaran
• Cystic Fibrosis Inhaled Agents
• Cytogam RX Policy
• Dacogen Rx Policy
• Daklinza
• Daliresp Rx Policy
• DAW Override Rx Policy
• Diclegis
• Dificid Step Therapy
• Duexis and Vimovo
• Dutoprol Step Therapy
• Dysport RX Policy
• Egrifta RX Policy
• Elaprase Rx Policy
• Eligard RX Policy
• Embeda Rx Policy
• Emsam RX Policy
• Enbrel RX Policy
• Entresto
• Entyvio RX Policy
• Erivedge
• Erwinaze RX Policy
• Erythropoiesis Stimulating Agents RX Policy
• Esbriet and Ofev
• Exjade and Jadenu
• Fabrazyme RX Policy
• Farydak
• Fentanyl Short Acting Products
• Ferriprox RX Policy
• Fibric Acid Derivatives Step Therapy
• Firmagon RX Policy
• Flector and Pennsaid
• Forteo RX Policy
• Fulyzaq
• Fuzeon
• Gattex Rx Policy
• Gazyva Rx Policy
• Gilenya
• Gilotrif
• Gleevec
• Glucose Test Strips Step Therapy
• Gralise
• Growth Hormone RX Policy
• Halaven Rx Policy
• Harvoni
• Hepatitis B Agents
• Hepatitis C RX Policy
• Herceptin Rx Policy
• Hereditary Angioedema Medications Rx Policy
• Hetlioz
• High Dollar Rx Policy
• Horizant
• HP Acthar Gel RX Policy
• Humira RX Policy
• Ibrance
• Iclusig
• Ilaris RX Policy
• Imbruvica
• Incivek Rx Policy
• Increlex RX Policy
• Infergen Rx policy
• Inhaled Cystic Fibrosis Agents RX Policy
• Injectafer Rx Policy
• Inlyta
• Interferons for Multiple Sclerosis RX Policy
• Interleukins RX Policy
• Intra-Articular Hyaluronan Injections RX Policy
• Intranasal Corticosteroids Step Therapy
• Intravitreal Angiogenesis Inhibitors RX Policy
• Intron A Rx Policy
• Invokana Rx Policy
• Iressa
• Isotretinoin Step Therapy
• Istodax Rx Policy
• IV SC Immune Globulins
• Jakafi
• Jevtana RX Policy
• Juxtapid and Kynamro
• Kadcyla RX Policy
• Kalydeco
• Ketamine IV and Lidocaine IV Rx Policy
• Ketek RX Policy
• Keveyis
• Keytruda RX Policy
• Kineret RX Policy
• Korlym
• Krystexxa Rx Policy
• Kuvan
• Kyprolis RX Policy
• Lenvima
• Letairis Opsumit and Tracleer
• LMWH QL RX Policy
• Lonsurf
• Lumizyme and Myozyme RX Policy
• Lupaneta Rx Policy
• Lupron RX Policy
• Lynparza
• Makena RX Policy
• Mekinist
• Methadone QL RX Policy
• Migraine Quantity Limit
• Mitoxantrone RX Policy
• Movantik and Relistor
• Mozobil RX Policy
• Multiple Sclerosis Injectable Therapy RX Policy
• Myalept RX Policy
• Myleran RX Policy
• Myobloc RX Policy
• Naglazyme RX Policy
• Natpara RX Policy
• Neumega Rx Policy
• Neupro Step Therapy
• Nexavar
• Nonsedating Antihistamines ST RX Policy
• Northera
• Novantrone Rx Policy
• Nulojix Rx Policy
• Nuvigil and Provigil
• Odomzo
• Oleptro Rx Policy
• Olysio
• Omontys RX Policy
• Opdivo
• Ophthalmic Prostaglandins
• Opioid Dependence Agents
• Opioids Long Acting Step Therapy
• Orencia RX Policy
• Orkambi
• Osphena Step Therapy
• Otezla
• Otrexup Rasuvo
• Pancreatic Enzymes Step Therapy
• PegIntron Rx Policy
• Perjeta
• Pomalyst
• Praluent and Repatha
• Procysbi
• Prolia RX Policy
• Prostanoids RX Policy
• Proton Pump Inhibitors Quantity Limit
• Proton Pump Inhibitors Step Therapy
• Provenge
• Qualaquin
• Quantity Limit Recommendations
• Qutenza
• Ranexa
• Ravicti
• Rebif and Plegridy Rx Policy
• Reclast RX Policy
• Regranex RX Policy
• Relistor
• Remicade RX Policy
• Restasis
• Revlimid
• Rilutek
• Rituxan
• Sabril
• Samsca Quantity Limit
• Savella RX Policy
• Sedative Hypnotic Step Therapy
• Selzentry
• Sensipar
• SGLT2 Inhibitors
• Short Acting Opioids
• Signifor Signifor LAR
• Simponi RX Policy
• Simvastatin 80 mg
• Soliris Rx Policy
• Somatostatin Analogs RX Policy
• Somatuline Depot RX Policy
• Somavert RX Policy
• Sovaldi
• Sporanox Onmel Rx Policy
• Sprycel
• SSRIST RX Policy
• Stelara RX Policy
• Stivarga
• Suboxone and Subutex RX Policy
• Supprelin LA Rx Policy
• Sutent
• Sylatron RX Policy
• Sylvant Rx Policy
• Symlin Rx Policy
• Synagis RX Policy
• Synribo RX Policy
• Taclonex
• Tafinlar
• Tarceva
• Targretin
• Tasigna
• Tazorac and Fabior
• Tecfidera
• Technivie
• Temodar
• Testosterone Replacement Therapy RX Policy
• Thalomid
• Thrombopoietin Receptor Agonist RX Policy
• Thyrogen Rx Policy
• Topical and Buccal Testosterone Rx Policy
• Topical Antifungals Step Therapy
• Topical Corticosteroids Step Therapy
• Topical Retinoids
• Trelstar RX Policy
• Triptans QL Post-Limit RX Policy
• Triptans QL Rx Policy
• Triptans Step Therapy
• Truvada
• Tykerb
• Tysabri RX Policy
• Valchlor
• Vantas RX Policy
• Velcade Rx Policy
• Viberzi
• Victrelis
• Vidaza RX Policy
• Viekira
• Vimizim RX Policy
• Viscosupplements RX Policy
• Vistide
• Votrient
• Xalkori
• Xeljanz
• Xeloda
• Xenazine
• Xeomin RX Policy
• Xgeva
• Xiaflex Rx Policy
• Xifaxan
• Xolair RX Policy
• Xtandi
• Xyrem
• Yervoy RX Policy
• Zaltrap RX Policy
• Zavesca
• Zelboraf
• Zohydro
• Zoladex RX Policy
• Zolinza
• Zometa RX Policy
• Zortress
• Zydelig
• Zykadia
• Zytiga