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 |
| 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, Rilutek, 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 |
| Daliresp | Daliresp |
| Daybue | Daybue |
| Depen | Depen, generic penicillamine tablets |
| Diacomit | Diacomit |
| Dichlorphenamide Products | Keveyis, Dichlorphenamide |
| Diclegis | Diclegis |
| Dojolvi | Dojolvi |
| Doptelet | Doptelet |
| Dupixent | Dupixent |
| Dysport | Dysport |
| 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 , Zavesca |
| General Oncology | Alecensa, Afinitor, Alunbrig, Augtyro, Ayvakit, Balversa, Besremi, Bexarotene, Bosulif, Brukinsa, Cabomeyx, Calquence, Camcevi, Caprelsa, Cometriq, Copiktra, Cotellic, Darzalex Faspro, Daurismo, Eligard, Erivedge, Erlotinib, Exkivity, Farydak, Fotivda, Fruzaqla, Gavreto, Gilotrif, Hyftor, Iclusig, Idhifa, Iwilfin, Imbruvica Capsules, Inqovi, Inlyta, Iressa, Jaypirca, Kisqali, Kisqali Femara co-pack, Krazati, Lapatinib, Lenalidomide, Lenvima, Libtayo, Lonsurf, Lorbrena, Lumakras, Lynparza, Lytgobi, Mekinist, Nexavar, Ninlaro, Odomzo, Ogsiveo, Ojjaara, Onureg, Orserdu, Orgovyx, Panretin, Pemazyre, Phyrago, Piqray, Pomalyst, Qinlock, Retevmo, Revlimid, Rezlidhia, 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, Viekira, 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 |
| 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 | Teriflunomide PA, Avonex, Betaseron, Copaxone, Extavia, Fingolimod, Glatopa, Mavenclad, Mayzent, Plegridy, Rebif, Dimethyl Fumarate, Vumerity, Zeposia, Bafiertam, Kesimpta, Ponvory and Tascenso |
| 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 |
| Nerlynx | Nerlynx |
| Nexletol | Nexletol |
| Nexlizet | Nexlizet |
| Northera | Northera |
| Nourianz | Nourianz |
| 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, 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 |
| PCSK9 Inhibitors | Praulent, Repatha |
| Phenylbutyrate Products | Ravicti, Olpruva, Pheburane and Buphenyl |
| Pheochromocytoma | Demser, Dibenzyline, Metyrosine, Phenoxybenzamine |
| Phesgo | Phesgo |
| 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 | Qbrexza |
| 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 |
| Rituxan | Rituxan, Riabni |
| 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 |
| Sunlenca | Sunlenca |
| Sunosi | Sunosi |
| Symdeko | Symdeko |
| Synarel | Synarel |
| Syprine | Syprine, Cuvrior |
| Tarpeyo | Tarpeyo |
| Tascenso ODT | Tascenso ODT |
| 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) |
| Tetrabenazine | Tetrabenazine |
| Tezspire | Tezspire |
| Thiola | tiopronine, Thiola EC |
| 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 |
| Trikafta | Trikafta |
| Tryvio | Tryvio |
| Tymlos | Tymlos |
| Tyrvaya | Tyrvaya |
| Ubrelvy | Ubrelvy |
| Ultomiris | Ultomiris |
| Velsipity | Velsipity |
| Valtoco | Valtoco |
| Veozah | Veozah |
| Veregen | Veregen |
| Verkazia | Verkazia |
| Verquvo | Verquvo |
| Viberzi | Viberzi |
| Vijoice | Vijoice |
| Vitrakvi | Vitrakvi |
| Vivjoa | Vivjoa |
| Voydeya | Voydeya |
| Voxzogo | Voxzogo |
| Vumerity | Vumerity |
| Vyleesi | Vyleesi |
| Vyndaqel, Vyndamax | Vyndaqel, Vyndamax |
| 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 |
| Zavzpret | Zavzpret |
| Zeposia | Zeposia |
| Zilbrysq | Zilbrysq |
| Zokinvy | Zokinvy |
| Ztalmy | Ztalmy |
| Zurzuvae | Zurzuvae |
| Zymfentra | Zymfentra |