Curing the World One Patient at a Time
TOLL FREE: 855.251.9116
[email protected]

Px Prior Authorization List of Selective Prescriptions

Rx AAlphabetical Table of Contents
View Full Size

$
400 Medications Requiring Prior Authorization in Alphabetical Order
...............

   A*

 ..........................

B* - C*

 ...........................

D* - E*

 ..........................

F* - G*

 ..........................

H* -I* - J* - K*

 
                        
Px Abilify®/
aripiprazole		 Px Baraclude®/
 entecavir		 Px Daliresp®/
roflumilast		 Px Fabior®/
tazarotene		 Px Hepsera®/
adefovir
Px Accolate®/
 zafirlukast		 Px Benicar®/
olmesartan		 Px Desoxyn®/
methamphetamine		 Px Fanapt®/
 iloperidone		 Px Hexelen®/
altretamine
Px Actemra®/
 tocilizumab		 Px Benicar® HCT/
 olmesartan		 Px Detrol®/
 tolterodine		 Px Farxiga®/
 dapagliflozin		 Px Humalog®/
insulin
Px Acthar®/
corticotropin		 Px Betaseron®/
interferon beta-1b 		Px Detrol®LA/
tolerodine		 Px Farydak®/
panobinostat		 Px Humira®/
adalimumab
Px Actonel®/
risedronate		 Px Bethkis®/
tobramycin mist		 Px Dexedrine®/
dextroamphetamine		 Px Fenoglide®/
fenofibrate		 Px Humulin®/
insulin
Px Adcirca®/
tadalafil		 Px Binosto®/
alendronate		 Px Dextorstat®/
dextroamphetamine		 Px Ferriprox®/
deferiprone		 Px Hycamtin®/
topotecan
Px Adderall®/
amphetamine
salts		 Px Boniva®/
ibandronate 		___Diabetes
Test strips		 Px Fetzima®/
levomilnacipran		 Px Hyzaar®/
losartan/ HCTZ
Px Adempas®/
riociguat		 Px Bosulif®/
bosutinib		 Px Dificid®/
fidaxomicin		 Px Fibricor®/
fenofibric acid
Px Advicor®/
niacin/ lovastatin		 Px Britellix®/
vortioxetine		 Px Diovan®/
valsartan		 Px Fibazyr®/
icatibant

I

Px Afinitor®/
everolimus 		Px Brisdelle®/
paroxetine		 Px Diovan® HCT/
valsartan/ HCTZ		 Px Flector®/
diclofenac		 Px Ibrance®/
palbociclib
Px Altoprev®/
lovastatin		 Px Brovana®/
arformoterol		 Px Dovonex® cream/
calcipotriene		 Px Forteo®/
teriparatide		 Px Imbruvica®/
ibrutinib
Px Amerge®/
naratriptan		 Px Bydureon®/
exenatide		 Px Fosrenol®/
lanthanum		 Px Imitrex®/
sumatriptan
Px Amitiza®/
lubiprostone		 Px Byetta®/
exenatide		 Px Frova®/
frovatriptan		 Px Icivek®/
telaprevir
Px Ampyra®/
dalfampridine		 Px Bystolic®/
nebivolol		 Px Fulyzaq®/
crofelemer		 Px Increlex®/
mecaserim
Px Amturnide®/
aliskiren/
amlodipine/ HCTZ		 Px Fuzeon®/
enfuviride		 Px Incruse Ellipta®/
umeclidinium
Px Ampyra®/
dalfampridine		 Px Fycompa®/
perampanel		 Px Inlyta®/
axitinib
Px Androgel®/
testosterone
cypionate topical		       
Px Antara®/
fenofibrate micro
___Insulin cartidges/
prefilled pens
Px Apidra®/
insulin glulisine		  
Px Intron® A/
interferon alfa-2b
Px Aplezin®/
bupropion
Px Invega®/
interferon alfa-2b
Px Aptiom®/
eslicarbazepine
Px Invega® Sustenna/
interferon alfa-2b
Px Aranesp®/
darbepoetin alfa
Px Invokamet®/
canagliflozin/ metformin
Px Arcalyst®/
rilonacept
Px Invokana®/
canagliflozin
...............

   A*

 ..........................

   C*

 ...........................

   E*

 ..........................

   G*

 ..........................

   J* - K*

                        
Px Aricept®23/
donepezil		 Px Caduet®/
amlodipine/
atorvastatin 		Px Edarbi®/
azilsartan		 Px Galzin®/
zinc		 Px Jadeni®/
deferasirox
Px Atacand®/
candesartan		 Px Caprelsa®/
vandetanib		 Px Edarbyclor®/
azilsartan/
chlorthiazide		 Px Gattex®/
teduglutide		 Px Jakafi®/
ruxolitinib
Px Atacand® HCl/
candesartan 		Px Cerdelga®/
eliglustat		 Px Effexor® XR/
venlafaxine ER		 Px Gelnique®/
oxybutynin		 Px Janumet®/
sitagliptin/
metformin
Px Atelvia®/
risedronate		 Px Cholbam®/
cholic acid		 Px Emend®/
aprepitant		 Px Giazo®/
balsalazide		 Px Janumet® XR/
sitagliptin/
metformin
Px Atralin®/
tretinon		 Px Cimzia®/
certolizumab		 Px Emsam® patch/
selegiline		 Px Gilenya®/
fingolimod		 Px Januvia®/
sitagliptin
Px Aubagio®/
teriflunomide		 Px Cometriq®/
cabozantinib		 Px Enablex®/
darifenacin		 Px Gilotrif®/
afatinib		 Px Jardiance®/
empagliflozin
Px Auryxia®/
ferric citrate		 Px Capaxone®/
glatiramer acetate 		Px Enbrel®/
etanercept		 Px Gleevec®/
imatinib		 Px Jentadueto®/
linagliptin/
metformin
Px Avalide®/
irbesartan/ HCTZ		 Px Cosentyx®/
secukinumab		 Px Epaned®/
enalapril		 Px Glyxambi®/
linagliptin/
empagliflozin		 Px Juxtapid®/
lomitapide
Px Avapro®/
irbesartan 		Px Cozaar®/
losartan		 Px Epogen®/
eroetin alfa		 Px Gralise®/
gabapentin
Px Avita® gel/
tretinoin		 Px Cresemba®/
isavuconazonium sulfate		 Px Erivedge®/
vismodegib		 Px Granix®/
tbo-filgrastim

K
Px Avonex®/
tretinon		 Px Crestor®/
rosuvastatin 		Px Esbriet®/
pirfenidone		 Px Growth
Hormone®/
somatropin		 Px Kalydeco®/
ivacaftor
Px Axert®/
teriflunomide		 Px Crinone® gel/
progesterone		 Px Exforge®/
amlodipine/
valsaratan		 Px Kineret®/
anakinra
Px Azor®/
candesartan		 Px Exforge®HCT/
amlodipine/
valsartan		 Px Kitabis®/
tobramycin
Px Exjade®/
deferasirox		 Px Kombiglyze®/
saxagliptin/
metformin
Extavia®/
interferon beta-1b		 Px Korlym®/
mifepristone
Px Kuvan®/
sapropterin
 

............

L*- M* -N*

 ..............

O* -P* -Q*

........................

R* - S*

......................

T* - U*

..................

V*-W*-X*-Y*-Z*

Px Lantus®/
 insulin glargine		 Px Ofev®/
nintedanib		 Px Ranitidine®/
Zantac®		 Px Tafinlar®/
dabrafenib		 Px Valchor®/
mechlorethamine
Px Latuda®/
lurasidone		 Px Olysio®/
simeprevir		 Px Ravicti®/
buphenyl		 Px Tagamet® Oral Soln/
cimetidine		 Px Velphoro®/
sucroferric
oxyhydroxide
Px Lenvima®/
lenvatinib		 Px Omontys®/
peginesatide		 Px Rebif®/
interferon beta-1a		 Px Tanzeum®/
albiglutide		 Px Venlafaxine® SR/
venlafaxine
Px Lescol®/
fluvastatin 		Px Onfi®/
clobazam		 Px Relistor®/
methyl-
naltrexone		 Px Tarceva®/
erlotinib		 Px Versacloz® Susp/
clozapine
Px Lescol®XL/
 fluvastatin		 Px Onglyza®/
saxagliptin 		Px Relpax®/
eletriptan		 Px Targretin®/
bexarotene		 Px Vesicare®/
solifenacin
Px Letaris®/
ambrisentan 		Px Opsumit®/
 macitentan 		Px Renagel®/
 sevelamer 		Px Tasigna®/
nilotinib		 Px Vfend®/
/voriconazole
Leukine®/
sargramostim 		Orbivac®/
oritavancin 		Renvela®/
sevelamer		 Tazorac®/
tazarotene		 Victoza®/
liraglutide
Levemir®/
 insulin detemir		 Orbivan®CF/
butalbital, acetaminophen 		Requip® XL/
ropinrole		 PxTecfidera®/
dimethyl fumarate		 Victrelis®/
boceprevir
Linzess®/
linaclotide 		Orencia®/
abatacept		 Retin-A®/
tretinoin		 Tekalmo®/
aliskiren/ amlodipine		 Viekira®/
dasabuvir/ ombitasvir/ paritaprevir
Lipofen®/
fenofibrate 		Orenitram®/
treprostinil		 Revatio®/
sildenafil		 Tekturna®/
aliskiren		 Viibryd®/
vilazodone
Liptruzet®/
etetimibe/ atorvastatin 		Oseni®/
alogliptin/ pioglitazone 		Revlimid®/
lenalidomide		 Tecturna® HCT/
aliskiren		 Vimpat®/
lacosamide
LoFibra®/
fenofibrate 		Otezla®/
apremilast 		Rhinocort® AQ/
budesonide 		Temodar®/
temozolomide		 Voltaren® Gel/
diclofenac
Lumigan®/
bimatoprost 		Oxtellar®/
oxcarbazepine
Teveten®/
eprosartan		 Voltrient®/
pazopanib
Lynparza®/
pazopanib 		Oxytrol® patch/
oxybutynin

S

 Treveten® HCT/
eprosartan		 Vytorin®/
ezetimibe/ simvastatin
Lyrica® Oral Soln/
 pregabalin
Samsca®/
tolvaptan		 Thalomid®/
thalidomide		 Vyvanse®/
lisdexamfetamine
Lysodren®/
mitotane		 Sanctura®/
trospium		 Tobi®/
tobramycin

P

 Sanctura®XR/
trospium		 Tobi® Podhaler/
tobramycin

X

M

 Peg-Intron®/
peginterferon alfa-2b		 Sancuso®/
granisetron		 Tolterodine®/
tolterodine		 Xalkori®/
crizotinib
Maxalt®/
rizatriptan 		Pegasys®/
peginterferon alfa-2a		 Sandostatin®/
octreotide		 Toujeo®/
insulin gargine		 Xeljanz®/
tofacitinib
Mekinist®/
trametinib		 Pennsaid®/
diclofenac sodium		 Sandostatin®LAR/
octreotide		 Toviaz®/
fesoterodine		 Xeloda®/
capecitabine
Micardis®/
telmisartan		 Pepcid® Oral Susp/
famotidine		 Saphris®/
asenapine		 Tracleer®/
bosentan		 Xenazine®/
tetrabenazine
Micardis® HCT/
telmisartan/ HCT 		Perforomist® Nebulizer/
formoterol		 Sarafem®/
floxetine		 Trajenta®/
linagliptin		 Xifanax®/
rifaximin
Migrainal®/
dihydroergotamine mesylate		 Pexeva®/
paroxetine		 Savella®/
milnacipran		 Travatan®Z/
milnacipran		 Xigduo®XR/
dapagliflozin/ metformin
Merapex®/
pramipexole		 Phoslo®/
eliphos		 Selfemra®/
floxetine		 Tretin-X®/
tretinoin		 Xtandi®/
enzalutamide
Mircera® X/
methoxy-polyethylene glycol-epoetin beta		 Picato®/
ingenol mebutate		 Seroquel®XR/
quetiapine		 Tretinoin® topical/
tretinoin		 Xyrem®/
sodium oxybate
Movantik®/
naloxegol 		Plegridy®/
interferon beta-1a		 Signifor®/
parireotide		 Tribenzor®/
amlodipine/ HCTZ/ olmesartan
Moxatag®/
amoxicillin ER		 Pomalyst®/
pomalidomide		 Silenor®/
deoxepin		 Tricor®/
fenofibrate

Z
Myalept®/
metreleptin 		Potiga®/
ezogabine		 Simcor®/
niacin/ simvastatin		 Triglide®/
fenofibrate		 Zantac®/
ranitidine
Mybetriq®/
mirabegron		 Prevacid® Solutab/
lansoprazole		 Simponi®/
golimumab		 Trilipix®/
fenofibric acid		 Zelboraf®/
vemurafenib
Pristiq®/
desvenlafaxine		 Sorilux®/
calcipotriene		 Trulicity®/
dulagltide		 Zetia®/
ezetimibe

N

 Procentra® Oral Soln/
amphetamine		 Sotylize®/
sotalol hydrochloride		 Truvada®/
emtricitabine/ tenofovir		 Zioptan®/
tafluprost
Nascobal®/
cyanocobalamin		 Procrit®/
epoetin alfa		 Sovaldi®/
sofosbuvir		 Tudorza®/
aclidinium		 Zolinza®/
vorinostat
Natesto®/
testosterone		 Promacta®/
eltrombopag		 Sprix® Nasal Soln/
ketorolac		 Twynsta®/
amlodipine/ amlodipine		 Zomig®/
zolmitriptan
Natpara®/
parathyroid hormone		 Protonix® packet/
pantoprazole		 Sprycel®/
dasatinib		 Tykerb®/
lapatinib		 Zontivity®/
vorapaxar
Nesina®/
alogliptin		 Provigil®/
modafinil		 PxStelara®/
ustekinumab		 Tyzeka®/
telbivudine		 Zuplenz®/
ondansetron
Neulata®/
pegfilgrastim		 Prozac® weekly/
fluoxetine		 Stivarga®/
regorafenib		 Zydelig®/
idelalisib
Neumega®/
 Pulmozyme®/
oprelvekin		 Sutent®/
sunitinib

U

 Zyflo®/
zileuton
Neupogen®/
filgratim		 Purixan®/
filgrastim		 Sylatron®/
peginterferon alfa-2b		 Uloric®/
febuxostat		 Zyflo® CR/
zileuton
Neupro®/
rotigotine		 Symlinopen®/
pramlintide		 Zykadia®/
ceritinib
Nexavar®/
sorafenib

Q

 Synarel®/
nafarelin		 Zytiga®/
abiraterone
Nexium®/
esomeprazole		 Qualaquin®/
quinine		 Synagis®/
palivizumab
Nilandron®/
nilutamide
Northera®/
droxidopa
Noxafil®/
posaconazole
Nucynta®/
tapentadol
Nuedexta®/
dextromethorphan/ quinidine
Nuvigil®/
Nymalize®/
nimodipine


Copyrighted® 2015