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Prior Approval Drug List

NOTE: This list is for Non-Catamount Members.
Catamount Members should refer to Catamount Prior Approval Rx List.

We require prior approval for certain medications. Your doctor must consult the guidelines, and submit the appropriate form.

Updated: 04/29/2010

# = added to list 11/2009

drug	Generic Name	guidelines & Form
Accretropin	somatropin	Accretropin Guidelines Accretropin PA Form
Actiq	oral transmucosal fentanyl	Actiq Guidelines Actiq PA Form
Amevive	alefacept	Amevive Guidelines Amevive PA Form
Antagon	ganirelix acetate	Antagon Guidelines Antagon PA Form
Apokyn	apomorphine hydrochloride injection	Apokyn Guidelines Apokyn PA Form
Aranesp	darbepoetin alpha	Aranesp Guidelines Aranesp PA Form
Arixtra	fondaparinux	Arixtra Guidelines Arixtra PA Form
Avastin	bevacizumab	Avastin Guidelines Avastin PA Form
Avonex	interferon beta 1a	Avonex Guidelines Avonex PA Form
Baraclude	entecavir	Baraclude Guidelines Baraclude PA Form
Betaseron	interferon beta-1b	Betaseron Guidelines Betaseron PA Form
Botox	botulinum toxin type A	Botox Guidelines Botox PA Form
Bravelle	urofollitropin	Bravelle Guidelines Bravelle PA Form
Cetrotide	cetrorelix acetate	Cetrotide Guidelines Cetrotide PA Form
Cimzia	certolzumab	Cimzia Guidelines Cimzia PA Form
Copaxone	glatiramer acetate	Copaxone Guidelines Copaxone PA Form
Copegus	ribavirin	Copegus Guidelines Copegus PA Form
Emend	aprepitant	Emend Guidelines Emend PA Form
Enbrel	etanercept	Enbrel Guidelines Enbrel PA Form
Epogen	epoetin alpha	Epogen Guidelines Epogen PA Form
Erbitux	cetuximab	Erbitux Guidelines Erbitux PA Form
Extavia	interferon beta-1b	Extavia Guidelines Extavia PA Form
Fentora	oral transmucosal fentanyl	Fentora Guidelines Fentora PA Form
Fertinex	urofollitropin	Fertinex Guidelines Fertinex PA Form
Flolan	epoprostenol sodium	Flolan Guidelines Flolan PA Form
Follistim	follitropin beta	Follistm Guidelines Follistm PA Form
Fragmin	dalteparin	Fragmin Guidelines Fragmin PA Form
Genotropin	somatropin	Genotropin Guidelines Genotropin PA Form
Gleevec	imatinib	Gleevec Guidelines Gleevec PA Form
GnRHa	gonadotropin-releasing hormone agonists	GnRHa Guidelines GnRHa PA Form
Gonal-FRFP	follitropin alfa	Gonal-FRFP Guidelines Gonal-FRFP PA Form
Hepsera	adefovir dipivoxil	Hepsera Guidelines Hepsera PA Form
Humatrope	somatropin	Humatrope Guidelines Humatrope PA Form
Humira	adalimumab	Humira Guidelines Humira PA Form
Innohep	tinzaparin	Innohep Guidelines Innohep PA Form
Iressa	gefitinib injection	Iressa Guidelines Iressa PA Form
Kineret	anakinra	Kineret Guidelines Kineret PA Form
Letairis	ambrisentan	Letairis Guidelines Letairis PA Form
Lovenox	enoxaparin	Lovenox Guidelines Lovenox PA Form
Luveris	lutropin alfa	Luveris Guidelines Luveris PA Form
Meridia	sibutramine	Meridia Guidelines Meridia PA Form
Nexavar	sorafenib	Nexavar Guidelines Nexavar PA Form
Norditropin	somatropin	Norditropin Guidelines Norditropin PA Form
Novarel	chronic gonadotropin	Novarel Guidelines Novarel PA Form
Nutropin	somatropin	Nutropin Guidelines Nutropin PA Form
Nutropin AQ	somatropin	Nutropin AQ Guidelines Nutropin AQ PA Form
Omnitrope	somatropin	Omnitrope Guidelines Omnitrope PA Form
Ovidrel	choriogonadotropin alfa	Ovidrel Guidelines Ovidrel PA Form
Orencia	abatacept	Orencia Guidelines Orencia PA Form
Pegasys	pegylated interferon alfa-2a	Pegasys Guidelines Pegasys PA Form
Peg-Intron	pegylated interferon alfa-2b	Peg-Intron Guidelines Peg-Intron PA Form
Pergonal	follicle stimulating hormone & luteinizing hormone	Pergonal Guidelines Pergonal PA Form
Procrit	epoetin alpha	Procrit Guidelines Procrit PA Form
Pregnyl	chorionic gonadotropin	Pregnyl Guidelines Pregnyl PA Form
Profasi	chorionic gonadotropin	Profasi Guidelines Profasi PA Form
Protropin	somatropin	Protropin Guidelines Protropin PA Form
Rebetol	robavirin	Rebetol Guidelines Rebetol PA Form
Rebif	interferon beta-1b	Rebif Guidelines Rebif PA Form
Remicade	infliximab	Remicade Guidelines Remicade PA Form
Retin-A for members over age 41	N/A	Guidelines - N/A Retin-A PA Form
Repronex	menotropin	Repronex Guidelines Repronex PA Form
Revatio	sildenafil	Revatio Guidelines Revatio PA Form
Revlimid	lenalidomide	Revlimid Guidelines Revlimid PA Form
Rituxan	rituximab	Rituxan Guidelines Rituxan PA Form
Saizen	somatropin	Saizen Guidelines Saizen PA Form
Serostim	somatropin	Serostim Guidelines Serostim PA Form
Simponi #	golimumab	Simponi Guidelines Simponi PA Form
Soliris	eculizumab	Soliris Guidelines Soliris PA Form
Somatrem	somatropin	Somatrem Guidelines Somatrem PA Form
Somatropin	somatropin	Somatropin Guidelines Somatropin PA Form
Sporanox/ Itraconazole	itraconazole	Sporanox Guidelines Sporanox PA Form
Sprycel	dasatinib	Sprycel Guidelines Sprycel PA Form
Stelara #	ustekinumab	Stelara Guidelines Stelara PA Forms
Sutent	sunitinib malate	Sutent Guidelines Sutent PA Form
Synarel	nafarelin acetate	Synarel Guidelines Synarel PA Form
Tarceva	erlotinib	Tarceva Guidelines Tarceva PA Form
Tekturna	aliskiren	Tekturna Guidelines Tekturna PA Form
Temodar	temozolomide	Temodar Guidelines Temodar PA Form
Tev-tropin	somatropin	Tev-tropin Guidelines Tev-tropin PA Form
Tracleer	bosentan	Tracleer Guidelines Tracleer PA Form
Tykerb	lapatinib	Tykerb Guidelines Tykerb PA Form
Tysabri	natalizumab	Tysabri Guidelines Tysabri PA Form
Valtropin	somatropin	Valtropin Guidelines Valtropin PA Form
Ventavis	iloprost	Ventavis Guidelines Ventavis PA Form
Vidaza	azacitidine injections	Vidaza Guidelines Vidaza PA Form
Vyvanse	lisdexamfetamine dimesylate	Vyvanse Guidelines Vyvanse PA Form
Xolair	omalizumab	Xolair Guidelines Xolair PA Form
Xenical	orlistat	Xenical Guidelines Xenical PA Form
Zolinza	vorinostat	Zolinza Guidelines Zolinza PA Form
Zorbtive	somatropin	Zorbtive Guidelines Zorbtive PA Form
Zyvox	linezolid	Zyvox Guidelines Zyvox PA Form

Compounded Medications		Compounded Medications Guidelines Compounded Medications PA
"Dispense as written" ^{(Brand-Name Drugs with Generics Available)}		Guidelines - N/A Dispense as Written PA