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Out-of-Pocket Costs Rx Management Programs Prior Approval List Step Therapy Quantity Limits Preferred Brand Name List Generic Drugs Mail Order Pharmacy Tools and Resources Health & Wellness Newsletters Contact Us Health Care Reform for Employers
Catamount Prior Approval Drug List
We require prior approval for certain categories of medications.
Your doctor must consult the guidelines, and submit the appropriate form.
Search listing by:
- Drug Name: type brand name or generic name of drug in text box
- Alphabetical Order: click on any column header
Updated: 08-16-2012
| Brand Name Drug (Generic NAme) |
Guidelines & Form |
|---|---|
| Accretropin (somatropin) |
Guidelines PA Form |
| Actiq (oral transmucosal fentanyl) |
Guidelines PA Form |
| Amevive (Alefacept) |
|
|
Ampyra (dalfampridine) |
|
| Apokyn (apomorphine hydrochloride injection) |
|
| Aranesp (darbepoetin alpha) |
|
| Arixtra (fondaparinux) |
|
| Avastin (bevacizumab) |
|
| Avonex (interferon beta 1a) |
|
| Baraclude (entecavir) |
|
| Betaseron (interferon beta-1b) |
|
| Boniva IV (ibandronate sodium) |
|
| Botox (botulinum toxin type A) |
|
| Cimzia (certolzumab) |
Guidelines PA Form |
| Copaxone (glatiramer acetate) |
|
| Copegus (ribavirin) |
|
| Enbrel (etanercept) |
|
| Epogen (epoetin alpha) |
|
| Erbitux (cetuximab) |
|
|
Erivedge (vismodegib) |
|
| Extavia (interferon beta-1b) |
Guidelines PA Form |
| Fentora (oral transmucosal fentanyl) |
Guidelines PA Form |
| Flolan (epoprostenol sodium) |
|
| Fragmin (dalteparin) |
|
| Genotropin (somatropin) |
|
|
Gilenya (fingolimod) |
|
| Gleevec (imatinib) |
|
| Hepsera (adefovir dipivoxil) |
|
| Herceptin (trastuzumab) |
|
| Humatrope (somatropin) |
|
| Humira (adalimumab) |
|
| Immunoglobulin (n/a) |
|
| Innohep (tinzaparin) |
|
| Iressa (gefitinib injection) |
|
| Jevtana (cabazitaxel) |
|
|
Kalydeco (ivacaftor) |
|
| Kineret (anakinra) |
|
| Letairis (ambrisentan) |
|
| Lovenox (enoxaparin) |
|
| Neulasta (pegfilgrastim) |
|
| Neupogen (filgrastim) |
|
| Nexavar (sorafenib) |
|
| Norditropin (somatropin) |
|
| Nutropin (somatropin) |
|
| Nutropin AQ (somatropin) |
|
| Nuvigil (armodafinil) |
|
| Omnitrope (somatropin) |
Guidelines PA Form |
| Orencia (abatacept) |
|
| Pegasys (pegylated interferon alfa-2a) |
|
| Peg-Intron (pegylated interferon alfa-2b) |
|
| Procrit (epoetin alpha) |
|
| Prolia (denosumab) |
|
| Provenge (sipuleucel-T) |
|
| Provigil (modafinil) |
|
| Protropin (somatropin) |
|
| Rebetol (robavirin) |
|
| Rebif (interferon beta-1b) |
|
| Reclast (zoledronic acid) |
|
| Remicade (infliximab) |
Guidelines PA Form |
| Retin-A for members over age 41 (n/a) |
Guidelines - N/A PA Form |
| Revatio (sildenafil) |
|
| Revlimid (lenalidomide) |
|
| Rituxan (rituximab) |
|
| Saizen (somatropin) |
|
| Serostim (somatropin) |
|
| Seroquel (quetiapine) |
|
| Simponi (golimumab) |
|
| Soliris (eculizumab) |
|
| Somatrem (somatropin) |
|
| Somatropin (somatropin) |
|
| Sporanox / Itraconazole (itraconazole) |
|
| Sprycel (dasatinib) |
|
| Stelara (ustekinumab) |
Guidelines PA Forms |
| Sutent (sunitinib malate) |
|
| Tarceva (erlotinib) |
|
| Temodar (temozolomide) |
|
| Tev-tropin (somatropin) |
Guidelines PA Form |
| Tracleer (bosentan) |
|
|
Trajenta (linagliptin) |
|
| Tykerb (lapatinib) |
Guidelines PA Form |
| Tysabri (natalizumab) |
|
| Valtropin (somatropin) |
Guidelines PA Form |
| Vectibix (panitumumab) |
Guidelines PA Form |
| Ventavis (iloprost) |
|
| Vidaza (azacitidine injections) |
|
| Vpriv (velaglucerase alfa) |
|
| Vyvanse (lisdexamfetamine dimesylate) |
|
| Xolair (omalizumab) |
|
| Zolinza (vorinostat) |
|
| Zorbtive (somatropin) |
|
| Zyvox (linezolid) |
|
| Compounded Medications |
|
| Dispense as written (Brand-Name Drugs with Generics Available) |
Guidelines - N/A Dispense as Written PA |
| Forteo (teriparatide) |
|
| Medications without NDC |
Guidelines - N/A Dispense as Written PA |
| Medications on market less than 12 months |
Guidelines - N/A Dispense as Written PA |
| Livalo (Pitavastatin) |
|
| Simcor | |
| Zolpimist | |
| Kombiglyze | |
| Luvox | |
| Advicor (lovastatin / niacin) |
|
| Altoprev (lovastatin extended release) |
|
| Caduet (atovastatin / amlodipine) |
|
| Vytorin (simvastatin / ezetimibe) |
|
| Zetia (ezetimibe) |
|
| Famvir (famcyclovir) |
|
| Valtrex (valacyclovir) |
|
| Mirapex (pramipexole dihydrochloride) |
|
| Requix XL (ropinirole) |
|
| Singulair (montelukast) |
|
| Accolate (zafirlukast) |
|
| Zylfo, Zylfo CR (zileuton) |
|
| Intuniv (guanfacine) |
|
| Strattera (atomoxetine) |
|
| Aciphex (rabeprazole sodium) |
|
| Nexium (esomeprazole) |
|
| Dexilant (dexlansoprazole) |
Guidelines Form |
| Prevacid (lanxoprazole) |
|
| Prilosec (omeprazole) |
|
| Zegerid (omeprazole) |
|
| Cymbalta (duloxetine) |
|
| Lexapro (escitalopram oxalate) |
|
| Pristiq (desvenlafaxine) |
Guidelines Form |
| Prozac Weekly (fluoxetine) |
|
| Allegra (fexofenadine Hcl) |
|
| Clarinex (desloratadine) |
|
| Xyzal (levocetirizine) |
Guidelines Form |
| Zyrtec (cetirizine) |
|
| Celebrex (celecoxib) |
|
| Antara (fenofibrate) |
|
| Fenoglide (fenofibrate) |
|
| Fibricor (fenofibrate acid) |
Guidelines Form |
| Lipofen (fenofibrate capsules) |
Guidelines Form |
| Lofibra (fenofibrate capsules micronized) |
|
| Lovaza (omega-3 fatty acid) |
|
| Tricor (fenofibrate) |
|
| Triglide (fenofibrate) |
|
| Trilipix (fenofibrate acid) |
|
| Detrol (tolterodine) |
|
| Detrol LA (tolterodine) |
|
| Enablex (darifenacin) |
|
| Gelnique (transdermal oxybutynin) |
|
| Sanctura (trospium) |
|
| Sanctura XR (trospium) |
|
| Toviaz (fesoterodine) |
|
| Vesicare (solifenacin) |
|
| Atacand (candesartan cilexetil |
Guidelines |
| Atacand HCT (candesartan cilexetil with hydrochlorothiazide) |
Guidelines |
| Avalide (irbesartan with hydrochlorothiazide) |
Guidelines |
| Avapro (irbesartan) |
Guidelines |
| Azor (n/a) |
Guidelines |
| Benicar (olmesartan medoxomil) |
Guidelines |
| Benicar HCT (olmesartan medoxomil with hydrochlorothiazide) |
Guidelines |
| Cozaar (losartan) |
Guidelines |
| Diovan (valsartan) |
Guidelines |
| Diovan HCT (valsartan with hydrochlorothiazide) |
Guidelines |
| Exforge (amlopipine and valsartan) |
Guidelines |
| Hyzaar (losartan) |
Guidelines |
| Micardis (telmisartan) |
Guidelines |
| Micardis HCT (telmisartan with hydrochlorothiazide) |
Guidelines |
| Tekamlo (aliskiren/amlodipine) |
Guidelines |
| Teveten (eprosartan mesylate) |
Guidelines |
| Teveten HCT (eprosartan mesylate with hydrochlorothizide) |
Guidelines |
| Tekturna (aliskiren) |
Guidelines |
| Tekturna HCT (aliskiren-HCTZ) |
Guidelines |
| Twynsta (telmisartan/amlodipine) |
Guidelines |
| Ambien CR (zolpidem tartarate extended release) |
|
| Lunesta (eszopiclone) |
|
| Rozerem (ramelteon) |
Guidelines Form |
| Beconase AQ (beclomethasone nasal) |
Guidelines Form |
| Nasacort AQ (triamcinolone acetonide) |
Guidelines Form |
| Omnaris (ciclesonide) |
Guidelines Form |
| Rhinocort Aqua (budesonide nasal) |
Guidlines Form |
| Veramyst (bluticasone furoate) |
Guidelines Form |
| Amerge (naratriptan) |
Guidelines Form |
| Axert (almotriptan malate) |
Guidelines Form |
| Frova (frovatriptan succinate) |
Guidelines Form |
| Relpax (eletriptan hydrobromide) |
Guidelines Form |
| Treximet (sumatriptan & naproxen) |
Guidelines Form |
| Zomig (zolmitriptan) |
Guidelines Form |
| Bystolic (nebivolol) |
Guidelines Form |
| Coreg CR (carvedilol) |
|
| Actonel (risedronate sodium) |
|
| Actonel with Calcium (risedronate sodium with calcium) |
|
| Boniva (ibandronate sodium) |
|
| Fosamax D (alendronate sodium) |
|
| Avodart (dutasteride) |
|
| Lyrica (pregabalin) |
|
| Actos (pioglitazone) |
Guidelines Form |
| Actoplus Met (pioglitazone & metformin) |
Guidelines Form |
| Avandamet (rosiglitazone & metformin) |
Guidelines Form |
| Avandaryl (rosiglitazone & glimepiride) |
Guidelines Form |
| Avandia (rosiglitazone) |
Guidelines Form |
| Bayer Ascencia Elite & Autodisc/Breeze /Contour (n/a) |
Guidelines Form |
| Blood Glucose Test Strips (n/a) |
Guidelines Form |
| Byetta (exenatide) |
Guidelines Form |
| Duetact (pioglitazone & glimepiride) |
Guidelines Form |
| Janumet (sitagliptin & metformin) |
Guidelines Form |
| Januvia (sitagliptin) |
Guidelines Form |
| Onglyza (saxagliptin) |
Guidelines Form |
| Prestige (n/a) |
Guidelines Form |
| Roche Accuchek Compact (n/a) |
Guidelines Form |
| Surestep (n/a) |
Guidelines Form |
| Truetrack (n/a) |
Guidelines Form |
| Victoza (liraglutide) |
Guidelines Form |
| Advair (fluticasone & salmeterol) |
Guidelines Form |
| Symbicort (budesonide & formoterol) |
Guidelines Form |
| Azithromycin | Form |
| Azithromycin Oral Susp | Form |
| Factive | Form |
| Zmax | Form |
| Aplenzin | Form |
| Budeprion SR | Form |
| Budeprion XL | Form |
| Bupropion SR/ER | Form |
| Celexa | Form |
| Citalopram | Form |
| Cymbalta | Form |
| Fluoxetine | Form |
| Fluvoxamine | Form |
| Lexapro | Form |
| Luvox CR | Form |
| Paroxetine HCI | Form |
| Paroxetine CR (Paxil CR) |
Form |
| Paxil | Form |
| Paxil CR | Form |
| Pexeva | Form |
| Pristiq | Form |
| Prozac | Form |
| Prozac Weekly | Form |
| Sarafem | Form |
| Selfemra | Form |
| Wellbutrin SR | Form |
| Wellbutrin XL | Form |
| Aloxi | Form |
| Anzemet | Form |
| Cesamet | Form |
| Emend | Form |
| Kytril | Form |
| Kytril/Granisetron Oral Solution | Form |
| Granisol solution | Form |
| Sancuso | Form |
| Zofran | Form |
| Zuplenz | Form |
| Diflucan | Form |
| Fluconazole | Form |
| Itraconazole | Form |
| Lamisil | Form |
| Monistat 1 | Form |
| Monistat 3 | Form |
| Monistat 7 | Form |
| Monistat Dual Pak | Form |
| Sporanox< | Form |
| Terazol 3 | Form |
| Terbinafine | Form |
| Terazol 7 | Form |
| Zazole | Form |
| Atacand | Form |
| Atacand HCT | Form |
| Avalide | Form |
| Avapro | Form |
| Azor | Form |
| Benicar | Form |
| Benicar HCT | Form |
| Bystolic | Form |
| Catapres TTS Patches | Form |
| Cardura | Form |
| Cardura XL | Form |
| Cozaar/Losartan | Form |
| Diovan | Form |
| Diovan HCT | Form |
| Doxazosin | Form |
| Exforge | Form |
| Exforge HCT | Form |
| Hytrin | Form |
| Hyzaar | Form |
| Micardis | Form |
| Micardis HCT | Form |
| Tekturna | Form |
| Teveten | Form |
| Teveten HCT | Form |
| Allegra | Form |
| Allegra D | Form |
| Clarinex | Form |
| Clarinex D | Form |
| Claritin | Form |
| Claritin D | Form |
| Xyzal | Form |
| Xyzal Solution | Form |
| Zyrtec | Form |
| Zyrtec D | Form |
| Zyrtec Syrup | Form |
| Celebrex | Form |
| Famvir | Form |
| Valtrex | Form |
| Relenza | Form |
| Abilify | Form |
| Abilify DISCMELT | Form |
| Fanapt | Form |
| Fanapt Titration Pack | Form |
| Geodon | Form |
| Invega | Form |
| Risperdal | Form |
| Risperdal M-Tab | Formb |
| Risperidone | Form |
| Risperidone M-Tab | Form |
| Saphris | Form |
| Seroquel | Form |
| Seroquel XR | Form |
| Zyprexa | Form |
| Zyprexa Zydis | Form |
| Amevive | Form |
| Avonex | Form |
| Betaseron | Form |
| Byetta | Form |
| Cimzia | Form |
| Copaxone | Form |
| Enbrel | Form |
| Extavia | Form |
| Humira | Form |
| Humira Crohns Starter Pack | Form |
| Humira Psoriasis Starter Pack | Form |
| Kineret | Form |
| Peg-Intron Pens Kits | Form |
| Pegasys | Form |
| Rebif | Form |
| Rebif Titration Pack | Form |
| Soliris | Form |
| Actos | Form |
| Actos XR | Form |
| Actoplus Met | Form |
| Actoplus Met XR | Form |
| Avandamet | Form |
| Avandaryl | Form |
| Avandia | Form |
| Duetact | Form |
| Janumet | Form |
| Januvia | Form |
| Kombiglyze | Form |
| Onglyza | Forma |
| PrandiMet | Form |
| Symlin | Form |
| SymlinPen | Form |
| Victoza | Form |
| Alora | Form |
| Climara | Form |
| Climara Pro | Form |
| Elestrin | Form |
| Estraderm | Form |
| Estradiol transdermal | Form |
| Estrasorb | Form |
| Estrogel | Form |
| Evamist | Form |
| Menostar | Form |
| Vivelle | Form |
| Vivelle-Dot | Form |
| Sancuso | Form |
| Zofran | Form |
| Baraclude | Form |
| Hepsera | Form |
| Advair | Form |
| Advair Diskus | Form |
| Aerobid | Form |
| Aerospan | Form |
| Albuterol | Form |
| Alupent | Form |
| Alvesco | Form |
| Asmanex | Form |
| Astelin | Form |
| Atrovent HFA | Form |
| Atrovant Nasal | Form |
| Azmacort | Form |
| Beconase AQ | Form |
| Brovana | Form |
| Combivent | Form |
| Dulera | Form |
| Duo Neb | Form |
| Foradil | Form |
| Flonase | Form |
| Flovent | Form |
| Flunisolide | Form |
| Intal | Form |
| Iprotroprium Br. Nasal Spray | Form |
| Maxair | Form |
| Nasonex | Form |
| Nasacort | Form |
| Nasarel | Form |
| NebuPent | Form |
| Omnaris | Form |
| Patanase | Form |
| ProAir HFA | Form |
| Proventil HFA | Form |
| Pulmicort | Form |
| Pulmicort Respules |
Form |
| Rhinocort AQ | Form |
| TOBI | Form |
| Qvar | Form |
| Serevent | Form |
| Spiriva | Form |
| Stadol Nasal | Form |
| Symbicort | Form |
| Tilade | Form |
| Ventolin HFA | Form |
| Veramyst | Form |
| Xolair | Form |
| Xopenex HFA | Form |
| Adrenaclick | Form |
| Epipen | Form |
| Epipen Twinject | Form |
| Sandostatin LAR Depot | Form |
| Arixtra | Form |
| Fragmin | Form |
| Innohep | Form |
| Lovenox | Form |
| Celebrex | Form |
| Meloxicam | Form |
| Mobic | Form |
| Iressa | Form |
| Neumega | Form |
| Nexavar | Form |
| Revlimid | Form |
| Sprycel | Form |
| Sutent | Form |
| Tarceva | Form |
| Zolinza | Form |
| Restasis | Form |
| Actonel | Form |
| Alendronate | Form |
| Boniva | Form |
| Forteo | Form |
| Fosamax | Form |
| Fosamax Plus D | Form |
| Ditropan XL | Form |
| Oxybutynin XL | Form |
| Oxytrol Patch | Form |
| Geinique | Form |
| Actiq | Form |
| Duragesic | Form |
| Fentora | Form |
| Flector patch | Form |
| Lioresal intrathecal kit | Form |
| Lyric | Form |
| Narcotics containing Acetaminophen |
Form |
| Nucynta | Form |
| Oxycontin | Form |
| Rybix ODT | Form |
| Ryzolt | Form |
| Savella | Form |
| Suboxone | Form |
| Toradol | Form |
| Tramadol | Form |
| Tramadol/APAP | Form |
| Tramadol/ERP | Form |
| Ultram | Form |
| Ultram | Form |
| Ultracet | Form |
| AcipHex | Form |
| Kapidex | Form |
| Lansoprazole (Prevacid) |
Form |
| Nexium | Form |
| Omeprazole (Prilosec) |
Form |
| Prilosec Oral Suspension | Form |
| Prilosec OTC | Form |
| Pantoprazole (Protonix) |
Form |
| Prevacid SoluTab | Form |
| Zegerid | Form |
| Ambien/ Ambien CR |
Form |
| Dalmane | Form |
| Doral | Form |
| Edluar | Form |
| Halcion | Form |
| Lunesta | Form |
| Placidyl | Form |
| Prosom | Form |
| Restoril | Form |
| Rozerem | Form |
| Sonata | Form |
| Zolpimist | Form |
| Advicor | Form |
| Altoprev | Form |
| Caduet | Form |
| Crestor | Form |
| Lescol | Form |
| Lescol XL | Form |
| Lipitor | Form |
| Livalo | Form |
| Lovastatin | Form |
| Mevacor | Form |
| Pravachol | Form |
| Pravastatin | Form |
| Pravigard PAC | Form |
| Simvastatin | Form |
| Vytorin | Form |
| Zocor | Form |
| Diabetic Test Strips | Form |
| Amerge | Form |
| Axert | Form |
| Cambia | Form |
| Frova | Form |
| IB-Stat oral spray | Form |
| Imitrex | Form |
| Imitrex NS | Form |
| Imitrex Injection |
Form Injection |
| Imitrex (Refill Kit | Form |
| Maxalt | Form |
| Maxalt-MLT | Form |
| Relpax | Form |
| Stadol nasal spray |
Form |
| Sumavel DosePro spray |
Form |
| Treximet | Form |
| Zomig | Form |
| Zomig ZMT | Form |
| Zomig NS | Form |
| Adcirca | Form |
| Apokyn | Form |
| Arava | Form |
| Cabergoline | Form |
| Cordran Tape | Form |
| Caverject | Form |
| Cayston | Form |
| Dostinex | Form |
| Edex | Form |
| Januvia | Form |
| Letaris | Form |
| Lyrica | Form |
| Plan B | Form |
| Samsca | Form |
| Regranex | Form |
| Revatio | Form |
| Tracleer | Form |
| Tysabri | Form |
| Ventavis | Form |
| Vyvanse | Form |
