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Content with Policies & Guidelines Draft Self-Administered Drug Policies .

Resmetirom

Iqirvo® (elafibranor)

Livdelzi®(seladelpar)

Ocaliva® (obeticholic acid)

Androderm, AndroGel, Fortesta, Natesto, Striant, Testim, testosterone solution, Vogelxo, Jatenzo, Methitest, methyltestosterone capsule, Tlando, Anadrol-50, danazol, Oxandrin, Kyzatrex

Abrilada, Actemra, Amjevita, Bimzelx, Cimzia, Cosentyx, Cyltezo, Enbrel, Entyvio, Hadlima, Hulio, Humira, Hyrimoz/Adalimumab-adaz, Idacio, Kevzara, Kineret, Litfulo, Olumiant, Omvoh, Orencia,...

See Policy for list of drugs

Contraceptive Prior Authorization Program Summary

Adlyxin, Bydureon, Bydureon BCise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza

Berinert, Cinryze, Firazyr, Haegarda, Orladeyo, Ruconest, Takhzyro

Cutaquiq, Cuvitru, Gammagard, Gammaked, Gamunex-C, Hizentra, Hyqvia, Xembify

print Print Back Back Mandatory Generic/Member Pays the Difference Exception Prior Authorization Program...

Otezla

Prudoxin, Zonalon

Elidel, Eucrisa, Nujo, Nuju, Protopic

Abilify, Abilify Mycite, Caplyta, Clozapine ODT, Clozaril, Fanapt, FazaClo, Geodon, Invega ER, Latuda, Lybalvi, Rexulti, Risperdal, Risperdal M-Tab, Risperidone ODT, Saphris, Secuado, Seroquel,...

Carbaglu

Jublia, Kerydin, Sporanox, Tolsura

Aldara, Carac, diclofenac gel, Efudex, Fluroplex, Klisyri, Tolak, Zyclara,

Agamree, Emflaza

Genotropin, Humatrope, Ngenla, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Skytrofa, Sogroya, Zomacton, Zorbtive

Acthar Gel, Cortrophin Gel