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.

Search listing by:

Drug Name: type brand name or generic name of drug in text box
Alphabetical Order: click on any column header

Updated: 2-15-13

Brand Name Drug (Generic NAme)	Guidelines & Form

Erivedge (vismodegib)	Guidelines PA Form
Ampyra (dalfampridine)	Guidelines PA Form
Gilenya (fingolimod)	Guidelines PA Form
Victrelis (boceprevir)	Guidelines PA Form
Incevik (telaprevir)	Guidelines PA Form
Benlysta (belimumab)	Guidelines PA Form
Aubagio (teriflunomide)	Guidelines PA Form
Accretropin (somatropin)	Guidelines PA Form
Actiq (oral transmucosal fentanyl)	Guidelines PA Form
Amevive (Alefacept)	Guidelines PA Form
Antagon (ganirelix acetate)	Guidelines PA Form
Apokyn (apomorphine hydrochloride injection)	Guidelines PA Form
Aranesp (darbepoetin alpha)	Guidelines PA Form
Arixtra (fondaparinux)	Guidelines PA Form
Avastin (bevacizumab)	Guidelines PA Form
Avonex (interferon beta 1a)	Guidelines PA Form
Baraclude (entecavir)	Guidelines PA Form
Betaseron (interferon beta-1b)	Guidelines PA Form
Boniva IV (ibandronate sodium)	Guidelines PA Form
Botox (botulinum toxin type A)	Guidelines PA Form
Bravelle (urofollitropin)	Guidelines PA Form
Cetrotide (cetrorelix acetate)	Guidelines PA Form
Cialis FOR Benign Prostatic Hypertrophy ONLY (tadalafil)	Guidelines PA Form
Cimzia (certolzumab)	Guidelines PA Form
Copaxone (glatiramer acetate)	Guidelines PA Form
Copegus (ribavirin)	Guidelines PA Form
Enbrel (etanercept)	Guidelines PA Form
Epogen (epoetin alpha)	Guidelines PA Form
Erbitux (cetuximab)	Guidelines PA Form
Extavia (interferon beta-1b)	Guidelines PA Form
Eylea (aflibercept)	Guidelines PA Form
Fentora (oral transmucosal fentanyl)	Guidelines PA Form
Fertinex (urofollitropin)	Guidelines PA Form
Flolan (epoprostenol sodium)	Guidelines PA Form
Follistim (follitropin beta)	Guidelines PA Form
Fragmin (dalteparin)	Guidelines PA Form
Genotropin (somatropin)	Guidelines PA Form
Gleevec (imatinib)	Guidelines PA Form
GnRHa (gonadotropin-releasing hormone agonists)	Guidelines PA Form
Gonal-FRFP (follitropin alfa)	Guidelines PA Form
Hepsera (adefovir dipivoxil)	Guidelines PA Form
Herceptin (trastuzumab)	Guidelines PA Form
Humatrope (somatropin)	Guidelines PA Form
Humira (adalimumab)	Guidelines PA Form
Immunoglobulin (n/a)	Guidelines PA Form
Innohep (tinzaparin)	Guidelines PA Form
Iressa (gefitinib injection)	Guidelines PA Form
Jevtana (cabazitaxel)	Guidelines PA Form
Kalydeco (ivacaftor)	Guidelines PA Form
Kineret (anakinra)	Guidelines PA Form
Kyprolis (carfilzomib)	Guidelines PA Form
Letairis (ambrisentan)	Guidelines PA Form
Lovenox (enoxaparin)	Guidelines PA Form
Luveris (lutropin alfa)	Guidelines PA Form
Meridia (sibutramine)	Guidelines PA Form
Neulasta (pegfilgrastim)	Guidelines PA Form
Neupogen (filgrastim)	Guidelines PA Form
Nexavar (sorafenib)	Guidelines PA Form
Norditropin (somatropin)	Guidelines PA Form
Novarel (chronic gonadotropin)	Guidelines PA Form
Nutropin (somatropin)	Guidelines PA Form
Nutropin AQ (somatropin)	Guidelines PA Form
Nuvigil (armodafinil)	Guidelines PA Form
Omnitrope (somatropin)	Guidelines PA Form
Ovidrel (choriogonadotropin alfa)	Guidelines PA Form
Orencia (abatacept)	Guidelines PA Form
Pegasys (pegylated interferon alfa-2a)	Guidelines PA Form
Peg-Intron (pegylated interferon alfa-2b)	Guidelines PA Form
Pergonal (follicle stimulating hormone & luteinizing hormone)	Guidelines PA Form
Pregnyl (chorionic gonadotropin)	Guidelines PA Form
Procrit (epoetin alpha)	Guidelines PA Form
Profasi (chorionic gonadotropin)	Guidelines PA Form
Prolia (denosumab)	Guidelines PA Form
Provenge (sipuleucel-T)	Guidelines PA Form
Provigil (modafinil)	Guidelines PA Form
Protropin (somatropin)	Guidelines PA Form
Rebetol (robavirin)	Guidelines PA Form
Rebif (interferon beta-1b)	Guidelines PA Form
Reclast (zoledronic acid)	Guidelines PA Form
Remicade (infliximab)	Guidelines PA Form
Retin-A for members over age 41 (n/a)	Guidelines - N/A PA Form
Repronex (menotropin)	Guidelines PA Form
Revatio (sildenafil)	Guidelines PA Form
Revlimid (lenalidomide)	Guidelines PA Form
Rituxan (rituximab)	Guidelines PA Form
Saizen (somatropin)	Guidelines PA Form
Serostim (somatropin)	Guidelines PA Form
Seroquel (quetiapine)	Guidelines PA Form
Simponi (golimumab)	Guidelines PA Form
Soliris (eculizumab)	Guidelines PA Form
Somatrem (somatropin)	Guidelines PA Form
Somatropin (somatropin)	Guidelines PA Form
Sporanox / Itraconazole (itraconazole)	Guidelines PA Form
Sprycel (dasatinib)	Guidelines PA Form
Stelara (ustekinumab)	Guidelines PA Forms
Sutent (sunitinib malate)	Guidelines PA Form
Synarel (nafarelin acetate)	Guidelines PA Form
Tarceva (erlotinib)	Guidelines PA Form
Temodar (temozolomide)	Guidelines PA Form
Tev-tropin (somatropin)	Guidelines PA Form
Tracleer (bosentan)	Guidelines PA Form
Tykerb (lapatinib)	Guidelines PA Form
Tysabri (natalizumab)	Guidelines PA Form
Valtropin (somatropin)	Guidelines PA Form
Vectibix (panitumumab)	Guidelines PA Form
Ventavis (iloprost)	Guidelines PA Form
Vidaza (azacitidine injections)	Guidelines PA Form
Vpriv (velaglucerase alfa)	Guidelines PA Form
Xolair (omalizumab)	Guidelines PA Form
Xenical (orlistat)	Guidelines PA Form
Zolinza (vorinostat)	Guidelines PA Form
Zorbtive (somatropin)	Guidelines PA Form
Zyvox (linezolid)	Guidelines 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
Forteo (teriparatide)	Guidelines PA Form
Livalo (Pitavastatin)	Guidelines Form
Simcor (n/a)	Guidelines Form
Zolpimist (n/a)	Guidelines Form
Kombiglyze (n/a)	Guidelines Form
Luvox (n/a)	Guidelines Form
Advicor (lovastatin / niacin)	Guidelines Form
Altoprev (lovastatin extended release)	Guidelines Form
Caduet (atovastatin / amlodipine)	Guidelines Form
Vytorin (simvastatin / ezetimibe)	Guidelines Form
Zetia (ezetimibe)	Guidelines Form
Famvir (famcyclovir)	Guidelines Form
Valtrex (valacyclovir)	Guidelines Form
Singulair (montelukast)	Guidelines Form
Accolate (zafirlukast)	Guidelines Form
Zylfo, Zylfo CR (zileuton)	Guidelines Form
Intuniv (guanfacine)	Guidelines Form
Strattera (atomoxetine)	Guidelines Form
Aciphex (rabeprazole sodium)	Guidelines Form
Nexium (esomeprazole)	Guidelines Form
Dexilant (dexlansoprazole)	Guidelines Form
Prilosec (omeprazole)	Guidelines Form
Zegerid (omeprazole)	Guidelines Form
Pristiq (desvenlafaxine)	Guidelines Form
Prozac Weekly (fluoxetine)	Guidelines Form
Clarinex (desloratadine)	Guidelines Form
Xyzal (levocetirizine)	Guidelines Form
Celebrex (celecoxib)	Guidelines Form
Antara (fenofibrate)	Guidelines Form
Fenoglide (fenofibrate)	Guidelines Form
Fibricor (fenofibrate acid)	Guidelines Form
Lipofen (fenofibrate capsules)	Guidelines Form
Lofibra (fenofibrate capsules micronized)	Guidelines Form
Lovaza (omega-3 fatty acid)	Guidelines Form
Triglide (fenofibrate)	Guidelines Form
Trilipix (fenofibrate acid)	Guidelines Form
Detrol (tolterodine)	Guidelines Form
Detrol LA (tolterodine)	Guidelines Form
Enablex (darifenacin)	Guidelines Form
Gelnique (transdermal oxybutynin)	Guidelines Form
Sanctura (trospium)	Guidelines Form
Sanctura XR (trospium)	Guidelines Form
Toviaz (fesoterodine)	Guidelines Form
Vesicare (solifenacin)	Guidelines Form
Azor (n/a)	Guidelines Form
Benicar (olmesartan medoxomil)	Guidelines Form
Benicar HCT (olmesartan medoxomil with hydrochlorothiazide)	Guidelines Form
Exforge (amlopipine and valsartan)	Guidelines Form
Micardis (telmisartan)	Guidelines Form
Micardis HCT (telmisartan with hydrochlorothiazide)	Guidelines Form
Tekamlo (aliskiren/amlodipine)	Guidelines Form
Teveten (eprosartan mesylate)	Guidelines Form
Teveten HCT (eprosartan mesylate with hydrochlorothizide)	Guidelines Form
Tekturna (aliskiren)	Guidelines Form
Tekturna HCT (aliskiren-HCTZ)	Guidelines Form
Twynsta (telmisartan/amlodipine)	Guidelines Form
Lunesta (eszopiclone)	Guidelines Form
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
Actonel (risedronate sodium)	Guidelines Form
Actonel with Calcium (risedronate sodium with calcium)	Guidelines Form
Boniva (ibandronate sodium)	Guidelines Form
Fosamax D (alendronate sodium)	Guidelines Form
Avodart (dutasteride)	Guidelines Form
Lyrica (pregabalin)	Guidelines Form
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
Bydureon (exenatide extended-release)	Guidelines Form
Duetact (pioglitazone & glimepiride)	Guidelines Form
Janument (sitagliptin & metformin)	Guidelines Form
Januvia (sitagliptin)	Guidelines Form
Onglyza (saxagliptin)	Guidelines Form
Trajenta (linagliptin)	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	Form
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
Antagon	Form
Bravelle	Form
Cetrotide	Form
Fertinex	Form
Follistim	Form
Gonal-F	Form
Menopur	Form
Novarel	Form
Ovidrel	Form
Pregnyl	Form
Profasi	Form
Repronex	Form
Synarel	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
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
Meridia	Form
Xenical	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