Drugs That May Require Prior Authorization
Click on the Drug Class to see the Criteria In Use by Medical Mutual for coverage approval.
| Drug Class | Drugs in Class |
|---|---|
| Acthar | Acthar Gel, Cortrophin gel |
| Actimmune | Actimmune |
| Acyclovir Topicals | Acyclovir 5% ointment, acyclovir 5% cream |
| Adakveo | Adakveo |
| Adbry | Adbry |
| Addyi | Addyi |
| Agamree | Agamree |
| Alyftrek | Alyftrek |
| Amvuttra | Amvuttra |
| Anticoagulants | Eliquis, Pradaxa, Xarelto |
| Antipsoriatic Agents | Otezla, Stelara, Taltz, Tremfya |
| Apokyn, Kynmobi | Apokyn, Kynmobi |
| Arcalyst | Arcalyst |
| Arikayce | Arikayce |
| Attention Deficit Hyperactivity Disorder Non-Stimulant Medications | Atomoxetine, Clonidine ER, Guanfacine ER, Intuniv, Kapvay, Strattera |
| Auryxia | Auryxia |
| Austedo | Austedo, Austedo XR |
| Benlysta | Benlysta |
| Bimzelx | Bimzelx |
| Botox | Botox |
| Branded Riluzole Products | Exservan, Tiglutik Kit |
| Brimonidine | Brimonidine |
| Briumvi | Briumvi |
| Bronchitol | Bronchitol |
| Bylvay | Bylvay |
| Cabenuva | Cabenuva |
| Cablivi | Cablivi |
| Calcitonin Gene-Related Peptide (CGRP) Antagonist | Aimovig (erenumab-aooe), Ajovy (fremanezumab-vfrm), Emgality (galcanezumab-gnlm) |
| Camyzos | Camyzos |
| Cayston | Cayston |
| Cequa | Cequa |
| Cholbam | Cholbam |
| Cialis | Cialis (2.5 & 5 MG) |
| Cibinqo | Cibinqo |
| Colony Stimulating Factors | Fulphila, Flynetra, Neulasta, Nyvepria, Stimufend, Udenyca, and Ziextenzo, Leukine, Granix, Releuko, Neupogen, Nivestym and Zarxio |
| Continuous Glucose Monitors | Dexcom G4, Dexcom G5, Dexcom G7, Enlite, Freestyle Navigator, Guardian, Minlink Real-Time, Minimed 630G Guardian, Paradigm Real-Time, Seven System, SOF , Eversense, Freestyle Libre, Dexcom G6 |
| Contraceptive Agents | All contraceptive agents not being prescribed for contraceptive purposes |
| Corlanor | Corlanor |
| Cosentyx | Cosentyx |
| Cosentyx IV | Cosentyx IV |
| Crysvita | Crysvita |
| Cystadane | Cystadane, betaine anhydrous |
| Dalfampridine | Dalfampridine |
| Daybue | Daybue |
| Depen | Depen, generic penicillamine tablets |
| Diacomit | Diacomit |
| Dichlorphenamide Products | Keveyis, Dichlorphenamide |
| Diclegis | Diclegis |
| Dojolvi | Dojolvi |
| Doptelet | Doptelet |
| Dupixent | Dupixent |
| Duvyzat | Duvyzat |
| Dysport | Dysport |
| Ebglyss | Ebglyss |
| Egrifta | Egrifta, Egrifta SV |
| Eltrombopag Products | Alvaiz, Promacta |
| Emflaza | Emflaza |
| Empaveli | Empaveli |
| Endari | Endari |
| Enspryng | Enspryng |
| Entresto | Entresto |
| Entyvio | Entyvio |
| Eohilia | Eohilia |
| Epidiolex | Epidiolex |
| Erythroid Stimulants | Aranesp, Epogen, Procrit and Retacrit, Mircera |
| Esbriet | Esbriet |
| Evenity | Evenity |
| Evkeeza | Evkeeza |
| Evrysdi | Evrysdi |
| Eysuvis | Eysuvis |
| Fabhalta | Fabhalta |
| Fasenra | Fasenra |
| Filspari | Filspari |
| Filsuvez | Filsuvez |
| Fintepla | Fintepla |
| Firdapse and Ruzurgi | Firdapse and Ruzurgi |
| Forteo, Bonsity | Forteo |
| Galafold | Galafold |
| Gamifant | Gamifant |
| Gattex | Gattex |
| Gaucher Disease Agents | Cerdelga, Miglustat, Yargesa, Zavesca |
| General Oncology | Alecensa, Afinitor, Alunbrig, Augtyro, Ayvakit, Balversa, Besremi, Bexarotene, Bosulif, Braftovi, Brukinsa, Cabomeyx, Calquence, Camcevi, Caprelsa, Cometriq, Copiktra, Cotellic, Danziten, Darzalex Faspro, Daurismo, Eligard, Ensacove, Erivedge, Erlotinib, Exkivity, Farydak, Fotivda, Fruzaqla, Gavreto, Gilotrif, Gomekli, Hyftor, Iclusig, Idhifa, Iwilfin, Imbruvica Capsules, Imkeldi, Inqovi, Inlyta, Iressa, Itovebi, Jaypirca, Krazati, Lapatinib, Lenalidomide, Lenvima, Libtayo, Lonsurf, Lorbrena, Lumakras, Lynparza, Lytgobi, Mekinist, Mektovi, Nexavar, Ninlaro, Odomzo, Ogsiveo, Ojjaara, Onureg, Orserdu, Orgovyx, Panretin, Pemazyre, Phyrago, Piqray, Pomalyst, Qinlock, Retevmo, Revlimid, Revuforj, Rezlidhia, Romvimza, Rubraca, Rydapt, Ryzneuta, Scemblix, Sorafenib, Sprycel, Stivarga, Sutent, Sunitinib,Tabrecta, Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin, Tasigna, Tazveric, Temodar, Temozolomide, Tepmetko, Thalomid, Tibsovo, Trelstar, Truseltiq, Truqap, Tukysa, Turalio, Tykerb, Ukoniq, Vandetanib, Venclexta, Verzenio, Vizimpro, Vonjo, Votrient, Xalkori, Xeloda, Xospata, Xpovio, Xtandi, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga |
| Givlaari | Givlaari |
| Global Prior Authorization | Exxua, Libervant, Macrilen, Pizensy, Tryvio, Vowst |
| GIP and GLP1 Agonist | Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza |
| Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty | Fensolvi, Lupron Depot-Ped, Supprelin LA, Triptodur |
| Gonadotropin-Releasing Hormone Agonists Long-Acting Agents | Lupaneta Pack, Lupron-Depot |
| Growth Hormones | Genotropin, Humatrope, Increlex, Norditropin, Nutropin, Omnitrope, Saizen, Serostim, Skytrofa, Zomacton, Zorbtive |
| HAE (Hereditary Angioedema) Agents | Berinert, Cinryze and Haegarda, Firazyr and Icatibant,Kalbitor, Ruconest, Takhzyro |
| Hemlibra | Hemlibra |
| Hepatitis C | Epclusa, Harvoni, Mavyret, Sovaldi, Vosevi, Zepatier |
| Hepatitis C Preferred Specialty Management | Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier |
| Hetlioz | Hetlioz, Hetlioz LQ |
| Hydroxyurea Products | Hydroxyurea Products |
| Ibrance | Ibrance |
| Ilaris | Ilaris |
| Ilumya | Ilumya |
| Imcivree | Imcivree |
| Imvexxy | Imvexxy |
| Inbrija | Inbrija |
| Inflammatory Care | Actemra, Amjevita, Cosentyx, Humira, Rinvoq, Sotyktu, Skyrizi, Stelara, Ilumya, Olumiant, Orencia SC, Otezla, Enbrel, Cimzia, Simponi SC, Kevzara, Kineret, Siliq, Taltz, Tremfya , Xeljanz/Xeljanz XR, Zeposia |
| Ingrezza | Ingrezza, Ingrezza Sprinkle |
| Inpefa | Inpefa |
| InPen Smart Insulin Pen | InPen Smart Insulin Pen |
| Inrebic | Inrebic |
| Intrarosa | Intrarosa |
| Iron Chelators - Oral | Deferasirox, Ferriprox |
| Isturisa | Isturisa |
| Ivermectin | Ivermectin |
| Jakafi | Jakafi |
| Jesduvroq | Jesduvroq |
| Joenja | Joenja |
| Juxtapid | Juxtapid |
| Jynarque and Tolvaptan | Jynarque and Tolvaptan |
| Kalydeco | Kalydeco |
| Kerendia | Kerendia |
| Kesimpta | Kesimpta |
| Kevzara | Kevzara |
| Kisqali | Kisqali |
| Korlym | Korlym |
| Koselugo | Koselugo |
| Lacrisert | Lacrisert |
| Leqselvi | Leqselvi |
| Leuprolide IR | Immediate Release Leuprolide products |
| Lidocaine Patches | Lidocaine Patches |
| Litfulo | Litfulo |
| Livmarli | Livmarli |
| Livtencity | Livtencity |
| Lupkynis | Lupkynis |
| Lybalvi | Lybalvi |
| Mavenclad | Mavenclad |
| Movantik & Symproic | Movantik & Symproic |
| Medical Device | V-Go Disposable Insulin Delivery Device |
| Miebo | Miebo |
| Mulpleta | Mulpleta |
| Multiple Sclerosis | Teriflunomide PA , Copaxone/Glatopa (glatiramer), Fingolimod, Interferon Beta Injectables, Mayzent, Dimethyl fumarate, Ponvory |
| Multiple Sclerosis Care Value | Avonex, Betaseron, Extavia, Mayzent, Plegridy, Rebif, Vumerity, Zeposia, Kesimpta, Ponvory |
| Multiple Sclerosis and Ulcerative Colitis – Zeposia Care Value Policy | Zeposia |
| Myalept | Myalept |
| Mycapssa | Mycapssa |
| Myfembree | Myfembree |
| Myobloc | Myobloc |
| Narcolepsy Products | Wakix, Xyrem, Xywav, Lumryz |
| Natpara | Natpara |
| Nayzilam | Nayzilam |
| Nemluvio | Nemluvio |
| Nerlynx | Nerlynx |
| Nexletol | Nexletol |
| Nexlizet | Nexlizet |
| Northera | Northera |
| Nourianz | Nourianz |
| Nucala | Nucala |
| Nuedexta | Nuedexta |
| Nulibry | Nulibry |
| Nuplazid | Nuplazid |
| Nurtec ODT | Nurtec ODT |
| Ocrevus | Ocrevus |
| Ocrevus Zunovo | Ocrevus Zunovo |
| Ofev | Ofev |
| Ohtuvayre | Ohtuvayre |
| Olumiant | Olumiant |
| Omega-3 Fatty Acid Products | Lovaza, Omega-3-Acid Ethyl Esters, Vascepa, Icosapent Ethyl, Triklo |
| Omvoh SC | Omvoh SC |
| Ongentys | Ongentys |
| Onpattro | Onpattro |
| Opfolda | Opfolda |
| Opioids | Extended Use Opioids (all opioid products not used for substance abuse treatment), Oxycontin (Oxycodone ER) 80 mg |
| Opzelura | Opzelura |
| Orencia SC | Orencia |
| Orfadin and Nityr | Orfadin, Nityr |
| Oriahnn | Oriahnn |
| Orilissa | Orilissa |
| Orkambi | Orkambi |
| Orladeyo | Orladeyo |
| Osphena | Osphena |
| Oxaydo | Oxaydo |
| Oxbryta | Oxbryta |
| Oxervate | Oxervate |
| Oxlumo | Oxlumo |
| Palforzia | Palforzia |
| Palynziq | Palynziq |
| Parathyroid Hormone Bone Modifiers | Teriparatide, Tymlos |
| PCSK9 Inhibitors | Praulent, Repatha |
| Phenylbutyrate Products | Ravicti, Olpruva, Pheburane and Buphenyl |
| Pheochromocytoma | Demser, Dibenzyline, Metyrosine, Phenoxybenzamine |
| Piasky | Piasky |
| Pombiliti | Pombiliti |
| Pulmonary Arterial Hypertension | Adempas, Endothelin Receptor Antagonist (ambristentan, bosentan, Letairis, Opsumit, Opsynvi, Tracleer), Epoprostenol (Veletri, Flolan), Inhaled Prostacyclins (Tyvaso, Ventavis), Orenitram, PDE-5 Inhibitors (Adcirca, Revatio, sildenafil, Tadliq), Treprostinil Products, Uptravi, |
| Pulmozyme | Pulmozyme |
| Pyrukynd | Pyrukynd |
| Qbrexza and Sofdra | Qbrexza and Sofdra |
| Qelbree | Qelbree |
| Qulipta | Qulipta |
| Radicava ORS | Radicava ORS |
| Reblozyl | Reblozyl |
| Recorlev | Recorlev |
| Relistor | Relistor |
| Restasis | Restasis |
| Revcovi | Revcovi |
| Reyvow | Reyvow |
| Rezurock | Rezurock |
| Rheumatological Agents | Actemra SC, Cimzia, Enbrel, Humira, Kineret, Simponi SC, Xeljanz and Xeljanz XR |
| Rhofade | Rhofade |
| Rivfloza | Rivfloza |
| Rinvoq | Rinvoq |
| Riomet | Riomet, Riomet ER |
| Rituxan | Rituxan, Riabni, Ruxience, Truxima |
| Rolvedon | Rolvedon |
| Rozlytrek | Rozlytrek |
| Ryzneuta | Ryzneuta |
| Sapropterin Products | Javygtor, Kuvan, Sapropterin Hydrochloride |
| Sensipar | Sensipar |
| Siliq | Siliq |
| Skyclarys | Skyclarys |
| Skyrizi | Skyrizi |
| Sohonos | Sohonos |
| Solaraze | Solaraze, diclofenac 3% gel |
| Soliris | Soliris |
| Soma (carisoprodol) | Soma, carisoprodol, combination carisoprodol products |
| Somavert | Somavert |
| Sotyktu | Sotyktu |
| Spevigo SC | Spevigo SC |
| Spravato | Spravato |
| Strensiq | Strensiq |
| Subcutaneous Immune Globulins | Cutaquig, Cuvitru, Gammagard Liquid, Gammaked, Gamunex-C, Hizentra, HyQvia, Xembify |
| Sublingual Immunotherapy (SLIT) | Grastek , Odactra, Oralair, Ragwitek |
| Sucraid | Sucraid |
| Sunleca | Sunleca |
| Sunosi | Sunosi |
| Symdeko | Symdeko |
| Synarel | Synarel |
| Syprine | Syprine, Cuvrior |
| Tarpeyo | Tarpeyo |
| Tavneos | Tavneos |
| Tavalisse | Tavalisse |
| Tegsedi | Tegsedi |
| Testosterone Injectables | Aveed (testosterone undecanoate), Azmiro, Delatestryl (testosterone enanthate), Depo®-Testosterone (testosterone cypionate), Testopel (testosterone) pellet, Testosterone Propionate, Testosterone propionate, Xyosted (testosterone enanthate subcutaneous injection) |
| Testosterone Topicals | Androderm patch, Androgel® 1.62% gel and Androgel 1% gel (testosterone 1.62% gel and testosterone 1% gel), Android, Methitest, Testred (methyltestosterone) , Androxy (fluoxymesterone) , Axiron™ (testosterone topical solution), Fortesta™ (testosterone 2% topical gel), Jatenzo (testosterone undecanoate), Natesto™ (testosterone nasal gel) , Striant® (testosterone buccal system), Testim® (testosterone 1% gel), Testosterone (generic oral formulations), Vogelxo (testosterone 1% gel) |
| Tetrabenazine | Tetrabenazine |
| Tezspire | Tezspire |
| Tiopronin Products | Tiopronine, Venxxiva |
| Tobi Podhaler | Tobi Podhaler |
| Topical Retinoids | Differin, generic adapalene topical, Epiduo, Altreno, Atralin, Avita, Retin-A, Tretin-X, generic topical tretinoin products, Fabior, Tazorac, tazarotene topical, Aklief |
| Transmucosal Fentanyl | Abstral, Actiq, fentanyl citrate, Fentora, Lazanda, Subsys |
| Transthyretin (TTR) Dissociation Inhibitors | Attruby, Vyndaqel, Vyndamax |
| Trikafta | Trikafta |
| Tryvio | Tryvio |
| Tyrvaya | Tyrvaya |
| Ubrelvy | Ubrelvy |
| Ultomiris | Ultomiris |
| Vafseo | Vafseo |
| Valtoco | Valtoco |
| Velsipity | Velsipity |
| Veozah | Veozah |
| Veregen | Veregen |
| Verkazia | Verkazia |
| Verquvo | Verquvo |
| Viberzi | Viberzi |
| Vijoice | Vijoice |
| Vitrakvi | Vitrakvi |
| Vivjoa | Vivjoa |
| Voydeya | Voydeya |
| Voxzogo | Voxzogo |
| Vumerity | Vumerity |
| Vyalev | Vyalev |
| Vyleesi | Vyleesi |
| Wainua | Wainua |
| Weight Loss Drugs | Adipex-P, Benzphetamine, Diethylpropion IR and CR, Lomaira, Phendimetrazine, Phentermine, Regimex, and Xenical |
| Weight Loss GLP1 Agonists PA | Saxenda, Wegovy, Zepbound |
| Weight Loss, Qsymia/Contrave | Qsymia, Contrave |
| Welireg | Welireg |
| Winlevi | Winlevi |
| Winrevair | Winrevair |
| Xatmep | Xatmep |
| Xcopri | Xcopri |
| Xdemvy | Xdemvy |
| Xeomin | Xeomin |
| Xermelo | Xermelo |
| Xgeva | Xgeva |
| Xiidra | Xiidra |
| Xolair | Xolair |
| Xolremdi | Xolremdi |
| Xphozah | Xphozah |
| Xuriden | Xuriden |
| Yorvipath | Yorvipath |
| Zavzpret | Zavzpret |
| Zeposia | Zeposia |
| Zilbrysq | Zilbrysq |
| Zokinvy | Zokinvy |
| Ztalmy | Ztalmy |
| Zurzuvae | Zurzuvae |
| Zymfentra | Zymfentra |