Medications

The following medications or classes of medications require prior authorization. Medications may appear more than once. Please verify you are selecting the medication in the correct category to ensure you download the correct form. Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in this list may occur. Physicians and pharmacy providers will be notified of any such changes via newsletters and direct mailings.

Medications Not Found
All new-to-market medications will require a Prior Authorization. If the medication you are looking for is a new-to-market drug, or is not listed, please complete the General Prior Authorization form.

Name Brand Medications with an available generic
Brand name drugs with an available generic requires the use of that generic. If there is a clinical reason the patient cannot use the generic, it is requires a Prior Authorization.

Medications requiring Prior Authorization

* These drugs require alternate site of care infusion other than outpatient hospital

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Medications requiring Step Therapy

BCBSKC will provide coverage for a Brand medication, only if the generic equivalent has been tried and failed; unless other step therapy or prior authorization requirements apply. Some medications may require two preferred alternatives before the name brand will be covered.

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Medications with Quantity Limits

Quantity limit refers to the amount of a drug needed to take the daily dose, according to the recommendations of the U.S. Food and Drug Administration (FDA). Quantity limits promote safe, cost-effective drug use and reduce waste and overuse. These limits are designed to control the use of selected drugs for quality and safety reasons. Prior authorization is required to go beyond the quantity limit.

The following list is subject to change and does not guarantee coverage. Use the search box at the top of this PDF to locate a specific drug.

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Medications that must be obtained from Specialty Pharmacy (30 Day Supply Limit)

  • Abacavir (ziagen)—Pharmacy Benefit
  • Abacavir/lamivudine/zidovudine—Pharmacy Benefit
  • Adempas (Riociguat)—Pharmacy Benefit
  • Alunbrig (brigatinib)—Pharmacy Benefit
  • Aptivus™ (tipranavir)—Pharmacy Benefit
  • Arikayce (amikacin inhalation soln)—Pharmacy Benefit
  • Atripla® (emtricidabine/efavirenz/tenofovir)—Pharmacy Benefit
  • Arixtra (fondaparinux sodium)—Pharmacy Benefit
  • Aubagio (Teriflunomide)—Pharmacy Benefit
  • Bavencio (Avelumab)—Medical Benefit
  • Cimzia (certolizumbegol) (for Rheumatoid Arthritis)—Pharmacy Benefit
  • Cimzia (certolizumbegol) (for Crohn's Disease)—Pharmacy Benefit
  • Combivir™ (lamivudine/zidovudine)—Pharmacy Benefit
  • Complera® (emtricidabine/rilpivirine/tenofovir)—Pharmacy Benefit
  • Copiktra (duvelisib)—Pharmacy Benefit
  • Cosentyx (for Psoriasis)—Pharmacy Benefit
  • Crixivan® (indinavir)—Pharmacy Benefit
  • Daklinza (daclatasvir)—Pharmacy Benefit
  • Didanosine—Pharmacy Benefit
  • Doptelet (avatrombopag)—Pharmacy Benefit
  • Dupixent (dupilumab)—Medical Benefit
  • Edurant® (rilpivirine)—Pharmacy Benefit
  • Emflaza (deflazacor)—Pharmacy Benefit
  • Emtriva™ (emtricidabine)—Pharmacy Benefit
  • Enbrel (etanercept) (For Psoriasis)—Pharmacy Benefit
  • Enbrel (etanercept) (For Rheumatoid Arthritis)—Pharmacy Benefit
  • Epidiolex (cannabidiol)—Medical Benefit
  • Epzicom® (abacavir/lamivudine)—Pharmacy Benefit
  • Evotaz™ (atazanavir/cobicistat)—Pharmacy Benefit
  • Extavia (interferon beta-1b)—Pharmacy Benefit
  • Fragmin (delteparin)—Medical or Pharmacy Benefit, does not require Prior Authorization
  • Fuzeon® (enfuvirtide)—Medical Benefit
  • Galafold (migalastat)—Pharmacy Benefit
  • Gileyna—Pharmacy Benefit
  • Growth Hormone Medications—Pharmacy Benefit
  • Harvoni (ledipasvir/sofosbuvir)—Pharmacy Benefit
  • Humira (adalimumab) (For Crohn's Disease)—Pharmacy Benefit
  • Humira (adalimumab) (For Psoriasis)—Pharmacy Benefit
  • Humira (adalimumab) (For Rheumatoid Arthritis)—Pharmacy Benefit
  • Idhifa (enasidenib)—Pharmacy Benefit
  • Ingrezza (Valbenzaine)—Pharmacy Benefit
  • Intelence™ (etravirine)—Pharmacy Benefit
  • Invirase® (saquinavir)—Pharmacy Benefit
  • Isentress® (raltegravir)—Pharmacy Benefit
  • Juxtapid (lomitapide)—Pharmacy Benefit
  • Kaletra® (lapinavir/ritonavir)—Pharmacy Benefit
  • Keveyis (dichlorphenamide)—Pharmacy Benefit
  • Kevzara (sarilumab)—Pharmacy Benefit
  • Kisqali (Ribociclib)—Pharmacy Benefit
  • Kisqali/Femara (Ribociclib/Letrozole)—Pharmacy Benefit
  • Kynamro (mipomersen sodium)—Medical Benefit
  • Lamivudine—Pharmacy Benefit
  • Lamivudine/zidovudine—Pharmacy Benefit
  • Lexiva™ (fosamprenavir)—Pharmacy Benefit
  • Lovenox (enoxaparin)—Medical or Pharmacy Benefit, does not require Prior Authorization
  • Lupaneta (leuprolide acetate depot)—Pharmacy Benefit
  • Lupron/Leuprolide—Medical or Pharmacy Benefit, does not require Prior Authorization
  • Mulpleta (lusutrombopag)—Pharmacy Benefit
  • Nerlynx (neratinib)—Pharmacy Benefit
  • Nevirapine—Pharmacy Benefit
  • Neviapine ER—Pharmacy Benefit
  • Norvir™ (ritonavir—Pharmacy Benefit)
  • Nucala (mepolizumab)—Medical Benefit
  • Nutropin AQ (somatropin)—Pharmacy Benefit
  • Ocaliva (obeticholic acid)—Pharmacy Benefit
  • Ocrevus (ocrelizumab)—Medical Benefit
  • Ofev (nintedanib)—Pharmacy Benefit
  • Olumiant (baricitinub)—Pharmacy Benefit
  • Omnitrope (somatropin)—Pharmacy Benefit
  • Opsumit (Macitentan)—Pharmacy Benefit
  • Orkambi (lumacaftor/ivacaftor)—Pharmacy Benefit
  • Otezla (apremilast) (For Psoriasis)—Pharmacy Benefit
  • Otezla (For Rheumatoid Arthritis)—Pharmacy Benefit
  • Pegylated Interferons—Pharmacy Benefit
  • Praluent (alirocumab)—Pharmacy Benefit
  • Prezcobix™ (darunavir/cobicistat)—Pharmacy Benefit
  • Prezista® (darunavir)—Pharmacy Benefit
  • Rescriptor™ (delavirdine mesylate)—Pharmacy Benefit
  • Retrovir™ (zidovudine)—Pharmacy Benefit
  • Reyataz® (atazanavir)—Pharmacy Benefit
  • Rydapt (midostaurin)—Pharmacy Benefit
  • Sabril (vigabatrin)—Pharmacy Benefit
  • Saizen (somatropin)—Pharmacy Benefit
  • Selzentry® (maraviroc)—Pharmacy Benefit
  • Siliq (brodalumab)—Pharmacy Benefit
  • Simponi (golimumab)—(for Crohn's Disease)—Pharmacy Benefit
  • Simponi (golimumab)—(for Rheumatoid Arthritis)—Pharmacy Benefit
  • Simponi Aria (golimumab)—(for Rheumatoid Arthritis)—Medical Benefit
  • Sovaldi (sofosbuvir)—Pharmacy Benefit
  • Spinraza (nusinersen/preservative free)—Medical Benefit
  • Stavudine—Pharmacy Benefit
  • Stribild™ (elvitegravir/cobicistat/emtricitabine/tenofovir)—Pharmacy Benefit
  • Sustiva™ (efavirenz)—Pharmacy Benefit
  • Symdeko (tezacaftor/ivacaftor)—Pharmacy Benefit
  • Takhzyro (lanadeumab-flyo)—Pharmacy Benefit
  • Taltz—Pharmacy Benefit
  • Talzenna (talazoparib)—Pharmacy Benefit
  • Tegsedi (inotersen)—Pharmacy Benefit
  • Tivicay® (dolutegravir)—Pharmacy Benefit
  • Tremfya (guselkumab)—Pharmacy Benefit
  • Triumeq™ (abacavir/dolutegravir/lamivudine)—Pharmacy Benefit
  • Trizivir™ (abacavir sulfate/lamivudine/zidovudine)—Pharmacy Benefit
  • Truvada® (emtricidabine/tenofovir)—Pharmacy Benefit
  • Tybost™ (cobicistat)—Pharmacy Benefit
  • Tymlos (abaloparatide)—Pharmacy Benefit
  • Tysabri (natalizumab) (For Crohn's Disease)—Medical Benefit * These drugs require alternate site of care infusion other than outpatient hospital
  • Tysabri (natalizumab) (For Multiple Sclerosis)—Medical Benefit * These drugs require alternate site of care infusion other than outpatient hospital
  • Verzenio (abemaciclib)—Pharmacy Benefit
  • Victrelis (boceprevir)—Pharmacy Benefit
  • Videx™ (didanosine)—Pharmacy Benefit
  • Videx™ EC (didanosine)—Pharmacy Benefit
  • Viracept™ (nelfinavir)—Pharmacy Benefit
  • Viramune™ (nevirapine)—Pharmacy Benefit
  • Viramune XR™ (nevirapine)—Pharmacy Benefit
  • Viread® (tenofovir disoproxil fumarate)—Pharmacy Benefit
  • Vitekta™ (elvitegravir)—Pharmacy Benefit
  • Vosevi (sofosbuvir/velpatasvir/voxilaprevir)—Pharmacy Benefit
  • Xeljanz (tofacitinib citrate)—Pharmacy Benefit
  • Xermelo (Telotristat)—Pharmacy Benefit
  • Xolair (omalizumab)—Medical Benefit
  • Xospata (gilteritinib)—Pharmacy Benefit
  • Zejula (Niraparib)—Pharmacy Benefit
  • Zepatier (elbasvir & grazoprevir)—Pharmacy Benefit
  • Zerit™ (stavudine)—Pharmacy Benefit
  • Ziagen™ (abacavir)—Pharmacy Benefit
  • Zidovudine—Pharmacy Benefit
  • Zomacton (somatropin)—Pharmacy Benefit

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Medications requiring prior authorization and obtained from Specialty Infusion Provider
(30 Day Supply Limit)

* Benefit exclusions may apply

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High Performance Forumlary Plans ONLY

The following medications or classes of medications require prior authorization for Exchange products and some small groups. Please verify you are selecting the medication in the correct category to ensure you download the correct form. Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in this list may occur. Physicians and pharmacy providers will be notified of any such changes via newsletters and direct mailings.

Medications Requiring Step Therapy

  • Actonel (risedronate)—Patient must first try a generic oral bisphophonate.
  • Actos (pioglitazone hydrochloride)—Patient must first try generic metformin, a metformin-containing combination product (brand or generic), or a pioglitazone-containing combination product.
  • Actoplus Met (pioglitazone hcl and metformin hcl)—Patient must first try generic metformin, a metformin-containing combination product (brand or generic), or a pioglitazone-containing combination product.
  • Actoplus Met XR (pioglitazone hcl and metformin hcl)—Patient must first try generic metformin, a metformin-containing combination product (brand or generic), or a pioglitazone-containing combination product.
  • Adderall XR (dextroamphetamine)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate
  • Ambien (zolpidem)
  • Amerge (naratriptan)—Patient must first try and fail a generic oral triptan.
  • Apidra (insulin glulisine [rDNAoring])
  • Aricept (donepezil hydrochloride)—Patients must first try and fail a generic ChI product (does NOT include donepezil 23 mg), THEN they must try and fail Aricept 5 and 10 mg.
  • Aricept ODT (donepezil hydrochloride)—Patients must first try and fail a generic ChI product (does NOT include donepezil 23 mg), THEN they must try and fail Aricept 5 and 10 mg.
  • Aricept 23 mg (donepezil hydrochloride)—Patients must first try and fail the requirements for Aricept above.
  • Atelvia (risedronate sodium)—Patient must first try an oral bisphosphonate tablet or generic ibandronate, THEN an oral bisphosphonate.
  • Avandia (rosiglitazone maleate)—Patient must first try generic metformin, a metformin-containing combination product (brand or generic), or a pioglitazone-containing combination product.
  • Avandamet (rosiglitazone maleate and metformin)—Patient must first try generic metformin, a metformin-containing combination product (brand or generic), or a pioglitazone-containing combination product.
  • Avandaryl (rosiglitazone maleate and glimepiride)—Patient must first try generic metformin, a metformin-containing combination product (brand or generic), or a pioglitazone-containing combination product.
  • Avodart (dutasteride)—Patients must first try and fail finasteride 5 mg.
  • Axert (almotriptain malate)—Patient must first try and fail a generic oral triptan.
  • Binosto (alendronate sodium) Patient must first try Step 1 oral bisphosphonate, then a Step 2 oral bisphosphonate.
  • Blocadren—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Boniva (ibandronate sodium)—Patient must first try Step 1 oral bisphosphonate, then a Step 2 oral bisphosphonate.
  • Brisdelle (paroxetine)—Patients must try and fail one SSRI.
  • Bystolic (nebivolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Cardura (doxazosin mesylate) Patient must fail a generic alpha-blocker.
  • Cardura XL (doxazosin mesylate)—Patient must fail a generic alpha-blocker.
  • Celexa (citalorpam)—Patients must try and fail one SSRI.
  • Cognex (tacrine)—Patients must first try and fail a generic ChI product (does NOT include donepezil 23 mg), THEN they must try and fail Aricept 5 and 10 mg.
  • Colestid—Patient must first try and fail a generic bile acid sequestrants.
  • Concerta (methylphenidate)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • ConZip (tramadol hydrochloride)—Patient must first try and fail a generic tramadol product.
  • Corgard (nadolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Coreg (carvedilol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Coreg CR (carvedilol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Corzide (nadolol and bendroflumethiazide)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Cymbalta (duloxetine)—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Daytrana (methylphenidate)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate
  • Depakote (divalproex sodium)—Patients must first try and fail a generic divalproex sodium or valproic acid product.
  • Depakote Sprinkle Capsules (divalproex sodium)—Patients must first try and fail a generic divalproex sodium or valproic acid product.
  • Depakote ER (divalproex sodium)—Patients must first try and fail a generic divalproex sodium or valproic acid product.
  • Depakene (valproic acid)—Patients must first try and fail a generic divalproex sodium or valproic acid product.
  • Desvenlafaxine extended-release—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Desvenlafaxine fumarate extended-release—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Dexedrine Spansules (dextroamphetamine)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate
  • Duetact (pioglitazone hydrochloride and glimepiride)—Patient must first try generic metformin, a metformin-containing combination product (brand or generic), or a pioglitazone-containing combination product.
  • Dutoprol (metroprolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Effexor (venlfaxine)—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Effexor XR (venlfaxine)—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Exelon (rivastigmine transdermal)—Patients must first try and fail a generic ChI product (does NOT include donepezil 23 mg), THEN they must try and fail Aricept 5 and 10 mg.
  • Exelon Patch (rivastigmine transdermal system)—Patients must first try and fail a generic ChI product (does NOT include donepezil 23 mg), THEN they must try and fail Aricept 5 and 10 mg.
  • Fetzima (levomilnacipran er)—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Flomax (tamsulosin HCI)—Patient must fail a generic alpha-blocker.
  • Fluoxetine 60 mg tablets—Patients must try and fail one SSRI.
  • Fluvoxamine—Patients must try and fail one SSRI.
  • Focalin XR (dexmethylphenidate hydrochloride)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • Fosamax (alendronate sodium)—Patient must first try Step 1 oral bisphosphonate, then a Step 2 oral bisphosphonate.
  • Fosamax Plus D (alendronate sodium)—Patient must first try Step 1 oral bisphosphonate, then a Step 2 oral bisphosphonate.
  • Frova (frovatriptan succinate)—Patient must first try and fail a generic oral triptan.
  • Hytrin (terazosin Hcl)—Patient must fail a generic alpha-blocker.
  • Imitrex (sumatriptan succinate)—Patient must first try and fail a generic oral triptan.
  • Inderal (propranolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Inderal LA (propranolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Inderal XL (propranolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Inderide (propranolol hydrochloride and hydrochlorothiazide)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • InnoPran XL (propranolol hydrochloride)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Intuniv (guanfacine)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate
  • Jalyn (dutasteride and tamsulosin hydrochloride)—Patients must first try and fail finasteride 5 mg.
  • Kapvay (clonidine hydrochloride)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate
  • Keppra (levetiracetam)—Patient must first try a generic levetiracetam product.
  • Keppra XR (levetiracetam)—Patient must first try a generic levetiracetam product.
  • Kerlone (betaxolol hydrochloride)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Khedezla (dezvenlafaxine extended release)—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Lamictal (lamotrigine)—Patient must first try and fail generic lamotrigine product.
  • Lamictal ODT (lamotrigine)—Patient must first try and fail generic lamotrigine product.
  • Lamictal XR (lamotrigine)—Patient must first try and fail generic lamotrigine product.
  • Levatol (penbutolol sulfate)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Lexapro (escitalopram)—Patients must try and fail one SSRI.
  • Lopressor (metoprolol tartrate)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Lopressor HCT (metoprolol tartrate)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Lumigan (bimatoprost ophthalmic solution)—Patients must first try and fail latanoprost or travoprost.
  • Luvox CR (fluvoxamin)—Patients must try and fail one SSRI.
  • Maxalt (rizatriptan benzoate)—Patient must first try and fail a generic oral triptan.
  • Maxalt MLT (rizatriptan benzoate)—Patient must first try and fail a generic oral triptan.
  • Metadate CD (methylphenidate hydrochloride)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate
  • Metadate ER (methylphenidate hydrochloride)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • Methylphenidate extended-release capsules (methylphenidate hydrochloride)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • Novolog (insulin aspart)
  • Oxtellar XR (oxcarbazepine)—Patients must first try and fail oxcarbaxepine tablets or oral suspension.
  • Paxil (paroxetine)—Patients must try and fail one SSRI.
  • Paxil CR (paroxetine)—Patients must try and fail one SSRI.
  • Pexeva (paroxetine mesylate)—Patients must try and fail one SSRI.
  • Prevalite (cholestyramine)—Patient must first try and fail a generic bile acid sequestrants.
  • Pristiq (desvenlafaxine)—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Proscar (finasteride)—Patients must first try and fail finasteride 5 mg.
  • Prozac (fluoxetine)—Patients must try and fail one SSRI.
  • Prozac Weekly (fluoxetine)—Patients must try and fail one SSRI.
  • Questran (cholestyramine)—Patient must first try and fail a generic bile acid sequestrants.
  • Questran Light—Patient must first try and fail a generic bile acid sequestrants.
  • Quillivant XR (cholestyramine)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • Rapaflo (silodosin)—Patient must fail a generic alpha-blocker.
  • Razadyne (galantamine)—Patients must first try and fail a generic ChI product (does NOT include donepezil 23 mg), THEN they must try and fail Aricept 5 and 10 mg.
  • Radadyne ER (galantamine HBr ER)—Patients must first try and fail a generic ChI product (does NOT include donepezil 23 mg), THEN they must try and fail Aricept 5 and 10 mg.
  • Relpax (eletriptain HBr)—Patient must first try and fail a generic oral triptan.
  • Rescula (unoprostone isopropyl)—Patients must first try and fail latanoprost or travoprost.
  • Ritalin-LA (methylphenidae hydrochloride)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • Ritalin-SR (methylphenidae hydrochloride)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • Rybix (tramadol HCI)—Patient must first try and fail a generic tramadol product.
  • Ryzolt (tramadol hydrochloride)—Patient must first try and fail a generic tramadol product.
  • Sarafem capsules (fluoxetine hydrochloride)—Patients must try and fail one SSRI.
  • Sarafem tablets (fluoxetine hydrochloride)—Patients must try and fail one SSRI.
  • Savella (milnacipran HC)—Patients must try and fail TWO SSRI (brand or generic) or SNRI (generic).
  • Sectral (acebutolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Strattera (atomoxetine)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • Stavzor (valproic acid)—Patients must first try and fail a generic divalproex sodium or valproic acid product.
  • Tenoretic (atenolol and chlorthalidone)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Tenormin (altenolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Toprol XL (metoprolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Tramadol Extended-Release—Patient must first try and fail a generic tramadol product.
  • Trandate (labetalol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Travatan Z (travoprost ophthalmic solution)—Patients must first try and fail latanoprost or travoprost.
  • Travoprost 0.0004% opthalmic solution—Patients must first try and fail latanoprost or travoprost.
  • Treximet (sumatriptan/naproxen sodium)—Patient must first try and fail a generic oral triptan.
  • Trileptal (oxcarbazepine)—Patients must first try and fail oxcarbaxepine tablets or oral suspension.
  • Trintellix (vortioxetine)—Patients must try and fail one SSRI.
  • Trulicity (dulaglutide)
  • Ultracet (tramadol hydrochloride and acetaminophen)—Patient must first try and fail a generic tramadol product.
  • Ultram (Tramadol Hcl)—Patient must first try and fail a generic tramadol product.
  • Ultram ER (Tramadol Hcl extended release)—Patient must first try and fail a generic tramadol product.
  • Uloric (febuxostat)—Patient must first try and fail allopurinol.
  • UroXatral (alfuzosin HCI)—Patient must fail a generic alpha-blocker.
  • Venlafaxine HCI—Patients must try and fail one SSRI (brand or generic) or SNRI (generic).
  • Victoza (liraglutide)
  • Viibryd (vilazodone)—Patients must try and fail one SSRI.
  • Visken (pindolol)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Vyvanse (lisdexamfetamine)—Patient must first try and fail a generic CNS stimulants such as and amphetamine or methlphenidate/dexmethylphenidate.
  • Welchol (colesevelam HCI)—Patient must first try and fail a generic bile acid sequestrants.
  • Xalatan (latanoprost)—Patients must first try and fail latanoprost or travoprost.
  • Zebeta (bisoprolol fumarate)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Ziac (bisoprolol and hydrochlorothiazide)—Patients must first try and fail a generic beta-blocker or a generic beta-blocker/diuretic combination.
  • Zioptan (tafluprost)—Patients must first try and fail latanoprost or travoprost.
  • Zoloft (sertraline)—Patients must try and fail one SSRI.
  • Zomig (zolmitriptan)—Patient must first try and fail a generic oral triptan.
  • Zomig ZMT (zolmitriptan)—Patient must first try and fail a generic oral triptan.

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Medications requiring Prior Authorization

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Federal Employee Advance Medical Review

The following medications or classes of medications require advance review. Please verify you are selecting the medication in the correct category to ensure you download the correct form. Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in this list may occur. Physicians and pharmacy providers will be notified of any such changes via newsletters and direct mailings.

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Is the drug you are requesting an oral, topical, or self-injectable medication?

If yes, please do not complete this form. Call Caremark PCS at 800-624-5060.

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