Prior Approval Drug List

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

***To obtain prior approval: ***

  • Call Express Scripts at (800) 313-7879 or
  • Use CoverMyMeds (online prior approval option)

 

Current Listing

Search listing by:

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

Prior Approval Drugs

Brand Name Sort descending ClassPrior Authorization Program
ABSTRAL
(FENTANYL CITRATE)
NARCOTICSANALGESICS
ADAGEN
(PEGADEMASE BOVINE)
MISCELLANEOUS AGENTSUNCLASSIFIED DRUG PRODUCTS
ADCETRIS
(BRENTUXIMAB INJECTION)
MISCELLANEOUSANTINEOPLASTICS
ADIPEX-P
(PHENTERMINE HCL)
ANOREXIANTSANTI-OBESITY DRUGS
ADVATE
(ANTIHEMOPHIL.FVIII,FULL LENGTH)
MISCELLANEOUS COAGULATION AGENTSBLOOD
ADVATE H
(ANTIHEMOPHIL.FVIII,FULL LENGTH)
MISCELLANEOUS COAGULATION AGENTSBLOOD
ADVATE L
(ANTIHEMOPHIL.FVIII,FULL LENGTH)
MISCELLANEOUS COAGULATION AGENTSBLOOD
ADVATE M
(ANTIHEMOPHIL.FVIII,FULL LENGTH)
MISCELLANEOUS COAGULATION AGENTSBLOOD
ADVATE SH
(ANTIHEMOPHIL.FVIII,FULL LENGTH)
MISCELLANEOUS COAGULATION AGENTSBLOOD
ADVATE UH
(ANTIHEMOPHIL.FVIII,FULL LENGTH)
MISCELLANEOUS COAGULATION AGENTSBLOOD
ADYNOVATE
(ANTIHEMO.FVIII,FULL LENGTH PEG)
MISCELLANEOUS COAGULATION AGENTSBLOOD
AFINITOR
(EVEROLIMUS)
MISCELLANEOUS ANTINEOPLASTIC DRUGSANTINEOPLASTICS
AFINITOR DISPERZ
(EVEROLIMUS)
MISCELLANEOUS ANTINEOPLASTIC DRUGSANTINEOPLASTICS
ALTRENO
(TRETINOIN)
THERAPY FOR ACNESKIN PREPS
AMEVIVE
(ALEFACEPT)
ANTIPSORIATIC / ANTISEBORRHEICSKIN PREPS
ANZEMET
(DOLASETRON MESYLATE)
ANTIVERTIGO & ANTIEMETIC AGENTSGASTROINTESTINAL
ARGININE
(ARGININE)
MISCELLANEOUS NUTRITION PRODUCTSELECT/CALORIC/H2O
ARMODAFINIL
(ARMODAFINIL)
MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTSPSYCHOTHERAPEUTIC DRUGS
ARYMO ER
(MORPHINE SULFATE)
NARCOTICSANALGESICS
ARZERRA
(OFATUZUMAB INJECTION)
MISCELLANEOUSANTINEOPLASTICS
ASTRAMORPH-PF
(MORPHINE SULFATE/PF)
NARCOTICSANALGESICS
AVINZA
(MORPHINE SULFATE)
NARCOTICSANALGESICS
AYVAKIT
(AVAPRITINIB TABLET)
KINASE INHIBITORANTINEOPLASTICS
AZEDRA DOSIMETRIC
(IOBENGUANE IODINE-131)
RADIOPHARMACEUTICALSANTINEOPLASTICS
AZEDRA THERAPEUTIC
(IOBENGUANE IODINE-131)
RADIOPHARMACEUTICALSANTINEOPLASTICS