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 |
|---|---|
| ACL Inhibitors | Nexletol, Nexlizet |
| Acthar | Acthar Gel |
| Actimmune | Actimmune |
| Acyclovir Topicals | Acyclovir 5% ointment, Zovirax 5% cream |
| Adakveo | Adakveo |
| Adbry | Adbry |
| Addyi | Addyi |
| Afinitor | Afinitor, Afinitor Disperz, everolimus |
| Ampyra | Ampyra |
| Amvuttra | Amvuttra |
| Androgens-Anabolic Steroids | Androl-50, Danazol, Nandrolone, Oxandrin |
| Anticoagulants | Eliquis, Pradaxa, Savaysa, 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 |
| Bafiertam | Bafiertam |
| Banzel | Banzel |
| Benlysta | Benlysta |
| Botox | Botox |
| Braftovi | Braftovi |
| Branded Riluzole Products | Exservan, Rilutek, Tiglutik Kit |
| Briumvi | Briumvi |
| Bronchitol | Bronchitol |
| Bylvay | Bylvay |
| Bynfezia | Bynfezia |
| 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, Fylnetra, Neulasta, Nyvepria, Udenyca, and Ziextenzo, Stimufend, Leukine, Granix, 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 |
| Crysvita | Crysvita |
| Cystadane | Cystadane, betaine anhydrous |
| Daliresp | Daliresp |
| Depen | Depen, generic penicillamine tablets |
| Diacomit | Diacomit |
| Diclegis and Bonjesta | Diclegis and Bonjesta |
| Dojolvi | Dojolvi |
| Doptelet | Doptelet |
| Dupixent | Dupixent |
| Dysport | Dysport |
| Egrifta | Egrifta |
| Emflaza | Emflaza |
| Empaveli | Empaveli |
| Endari | Endari |
| Enspryng | Enspryng |
| Entresto | Entresto |
| Entyvio | Entyvio |
| Epidiolex | Epidiolex |
| Erleada | Erleada |
| Erythroid Stimulants | Aranesp, Epogen, Procrit and Retacrit, Mircera |
| Esbriet | Esbriet |
| Evenity | Evenity |
| Evkeeza | Evkeeza |
| Evrysdi | Evrysdi |
| Eysuvis | Eysuvis |
| Fasenra | Fasenra |
| Fintepla | Fintepla |
| Firdapse and Ruzurgi | Firdapse and Ruzurgi |
| Forteo, Bonsity | Forteo, Bonsity |
| Galafold | Galafold |
| Gamifant | Gamifant |
| Gattex | Gattex |
| Gaucher Disease Agents | Cerdelga, Miglustat , Zavesca |
| General Oncology | Alecensa, Alunbrig, Ayvakit, Balversa, Besremi, Bexarotene, Bosulif, Brukinsa, Cabomeyx, Calquence, Camcevi, Caprelsa, Cometriq, Copiktra, Cotellic, Darzalex Faspro, Daurismo, Eligard, Erivedge, Erlotinib, Exkivity, Farydak, Fotivda, Gavreto, Gilotrif, Hyftor, Ibrance, Iclusig, Idhifa, Imbruvica Capsules, Inqovi, Inlyta, Iressa, Jaypirca, Krazati,Lapatinib, Lenalidomide, Lenvima, Libtayo, Lonsurf, Lorbrena, Lumakras, Lynparza, Lytgobi, Mekinist, Nexavar, Ninlaro, Odomzo, Onureg, Orserdu, Orgovyx, Panretin, Pemazyre, Piqray, Pomalyst, Qinlock, Retevmo, Revlimid, Rezlidhia, Rubraca, Rydapt, Scemblix, Sorafenib, Sprycel, Stivarga, Sutent, Sunitinib,Tabrecta, Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin, Tasigna, Tazveric, Temodar, Temozolomide, Tepmetko, Thalomid, Tibsovo, Trelstar, Truseltiq, Tukysa, Turalio, Tykerb, Ukoniq, Vandetanib, Venclexta, Verzenio, Vizimpro, Vonjo, Votrient, Xalkori, Xospata, Xpovio, Xtandi, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia |
| Givlaari | Givlaari |
| Gleevec | Gleevec, Imatinib |
| Global Prior Authorization | Brenzvvy, Filspari, Jesduvroq, Macrilen, Skyclarys |
| GIP and GLP1 Agonist | Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza |
| Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty | Fensolvi, Lupron Depot-Ped, 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, Viekira, Vosevi, Zepatier |
| Hepatitis C Preferred Specialty Management | Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier |
| Hetlioz | Hetlioz |
| 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 |
| InPen Smart Insulin Pen | InPen Smart Insulin Pen |
| Inrebic | Inrebic |
| Intrarosa | Intrarosa |
| Iron Chelators - Oral | Deferasirox, Exjade, Ferriprox, Jadenu, Jadenu Sprinkle |
| Isturisa | Isturisa |
| Ivermectin | Ivermectin |
| Jakafi | Jakafi |
| Juxtapid | Juxtapid |
| Jynarque and Samsca | Jynarque and Samsca |
| Kalydeco | Kalydeco |
| Kerendia | Kerendia |
| Kesimpta | Kesimpta |
| Kevzara | Kevzara |
| Kisqali | Kisqali |
| Korlym | Korlym |
| Koselugo | Koselugo |
| Lacrisert | Lacrisert |
| Leuprolide IR | Immediate Release Leuprolide products |
| Lidocaine Patch | Lidoderm or Lidocaine Patch, ZTlido |
| Livmarli | Livmarli |
| Livtencity | Livtencity |
| Lupkynis | Lupkynis |
| Luzu (luliconazole) | Luzu (luliconazole) |
| Lybalvi | Lybalvi |
| Lyrica CR | Lyrica CR |
| Mavenclad | Mavenclad |
| Medical Device | V-Go Disposable Insulin Delivery Device |
| Mektovi | Mektovi |
| Mulpleta | Mulpleta |
| Multiple Sclerosis | Aubagio, Copaxone/Glatopa (glatiramer), Gilenya, Interferon Beta Injectables, Mayzent, Dimethyl fumarate & Tecfidera, Ponvory |
| Multiple Sclerosis Care Value | Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa, Mavenclad, Mayzent, Plegridy, Rebif, Tecfidera, Vumerity, Zeposia |
| Multiple Sclerosis and Ulcerative Colitis – Zeposia Care Value Policy | Zeposia |
| Myalept | Myalept |
| Mycapssa | Mycapssa |
| Myfembree | Myfembree |
| Myobloc | Myobloc |
| Narcolepsy Products | Wakix, Xyrem, Xywav |
| Natpara | Natpara |
| Nayzilam | Nayzilam |
| Nerlynx | Nerlynx |
| Northera | Northera |
| Nourianz | Nourianz |
| Nubeqa | Nubeqa |
| Nucala | Nucala |
| Nuedexta | Nuedexta |
| Nulibry | Nulibry |
| Nuplazid | Nuplazid |
| Nurtec ODT | Nurtec ODT |
| Ocaliva | Ocaliva |
| Ocrevus | Ocrevus |
| Ofev | Ofev |
| Olumiant | Olumiant |
| Omega-3 Fatty Acid Products | Lovaza, Omega-3-Acid Ethyl Esters, Vascepa |
| Ongentys | Ongentys |
| Onpattro | Onpattro |
| Opioid Induced Constipation | Amitiza, Movantik, Relistor, Symproic |
| 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 |
| PCSK9 Inhibitors | Praulent, Repatha |
| Pheochromocytoma | Demser, Dibenzyline, Metyrosine |
| Phesgo | Phesgo |
| Pizensy | Pizensy |
| Promacta | Promacta |
| Provigil, Nuvigil | Provigil, Nuvigil |
| Pulmonary Arterial Hypertension | Adempas, Endothelin Receptor Antagonist (Tracleer, Letairis, Opsumit), Epoprostenol (Veletri, Flolan), Inhaled Prostacyclins (Tyvaso, Ventavis), Orenitram, PDE-5 Inhibitors (Adcirca, Revatio, sildenafil, Tadliq), Uptravi |
| Pulmozyme | Pulmozyme |
| Pyrukynd | Pyrukynd |
| Qbrexza | Qbrexza |
| Qelbree | Qelbree |
| Qulipta | Qulipta |
| Radicava ORS | Radicava ORS |
| Ravicti | Ravicti |
| Reblozyl | Reblozyl |
| Recorlev | Recorlev |
| Restasis | Restasis |
| Revcovi | Revcovi |
| Reyvow | Reyvow |
| Rezurock | Rezurock |
| Rheumatological Agents | Actemra SC, Cimzia, Enbrel, Humira (Amjevita), Kineret, Simponi SC, Xeljanz and Xeljanz XR |
| Rinvoq | Rinvoq |
| Riomet | Riomet |
| Rituxan | Rituxan |
| Rolvedon | Rolvedon |
| Rozlytrek | Rozlytrek |
| Sapropterin Products | Javygtor, Kuvan, Sapropterin Hydrochloride |
| Sensipar | Sensipar |
| Siliq | Siliq |
| Siklos | Siklos |
| Skyrizi | Skyrizi |
| Solaraze | Solaraze, diclofenac 3% gel |
| Soliris | Soliris |
| Soma (carisoprodol) | Soma, carisoprodol, combination carisoprodol products |
| Somatostatin Analogs | Sandostatin LAR, Signifor LAR, Somatuline Depot |
| Somatostatin Analogs Octreotide IR Products | Bynfezia, Sandostatin |
| Somavert | Somavert |
| Sotyktu | Sotyktu |
| 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 |
| Sunlenca | Sunlenca |
| Sunosi | Sunosi |
| Symdeko | Symdeko |
| Synarel | Synarel |
| Syprine | Syprine |
| Tarpeyo | Tarpeyo |
| Tavneos | Tavneos |
| Tavalisse | Tavalisse |
| Tegsedi | Tegsedi |
| Testosterone Injectables | Aveed (testosterone undecanoate), 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) |
| Tezspire | Tezspire |
| Thiola | Thiola |
| Tobi Podhaler | Tobi Podhaler |
| Topical Alpha-Adrenergic Agonists for Rosacea | Mirvaso, Rhofade |
| 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 |
| Trikafta | Trikafta |
| Tymlos | Tymlos |
| Tyrvaya | Tyrvaya |
| Ubrelvy | Ubrelvy |
| Ultomiris | Ultomiris |
| Valtoco | Valtoco |
| Veregen | Veregen |
| Verkazia | Verkazia |
| Verquvo | Verquvo |
| Viberzi | Viberzi |
| Vijoice | Vijoice |
| Vitrakvi | Vitrakvi |
| Vivjoa | Vivjoa |
| Voxzogo | Voxzogo |
| Vumerity | Vumerity |
| Vyleesi | Vyleesi |
| Vyndaqel, Vyndamax | Vyndaqel, Vyndamax |
| Weight Loss Drugs | Adipex-P, Benzphetamine, Contrave, Diethylpropion IR and CR, Lomaira, Phendimetrazine, Phentermine, Regimex, Qsymia ER and Xenical |
| Weight Loss GLP1 Agonists PA | Saxenda, Wegovy |
| Welireg | Welireg |
| Winlevi | Winlevi |
| Xatmep | Xatmep |
| Xcopri | Xcopri |
| Xenazine | Xenazine |
| Xeomin | Xeomin |
| Xermelo | Xermelo |
| Xgeva | Xgeva |
| Xiidra | Xiidra |
| Xolair | Xolair |
| Xuriden | Xuriden |
| Yonsa | Yonsa |
| Zelnorm | Zelnorm |
| Zeposia | Zeposia |
| Zokinvy | Zokinvy |
| Ztalmy | Ztalmy |
| Zytiga | Zytiga |