ClearScript Prior Authorization Drug List
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1 ClearScript Prior Authorization Drug List Prior authorization is a cost-savings program intended to ensure that medications are utilized in a manner that is consistent with your pharmacy benefit. For the medications included on the Prior Authorization Drug List, you may be required to get prior authorization before coverage is provided. Without prior authorization, the drug may not be covered. Filling Prescriptions with Prior Authorization If you are prescribed a medication that requires Prior Authorization, your physician will need to contact ClearScript at the number provided on your ID card to request a prior authorization review. Your physician will be required to provide clinical information regarding your use of the medication prescribed. ClearScript reviews your clinical information and specific prior authorization criteria to determine if the medication use is consistent with your benefit coverage. ClearScript will notify you and your physician of the coverage determination. Promoting Clinically Effective and Affordable Medications The goal of the Prior Authorization Program is to promote effective use of drugs based on nationally accepted treatment protocols or well documented clinical drug studies. The coverage criteria have been established based upon a review of currently available clinical information. These criteria are revised on an ongoing basis as clinical information changes and new guidelines and standards of care are updated. Refer to your plan documents or contact our Member Service Center toll-free at for more information. Drug Class Acne Medications ADAPALENE RETIN-A MICRO ATRALIN tretinoin AVITA tretinoin microspheres DIFFERIN TRETIN-X RETIN-A Allergy Therapy s grass pollen-orchard/sweet vernal/rye/kentucky/timothy, std. ORALAIR RAGWITEK grass pollen-timothy, std weed pollen-short ragweed GRASTEK Alzheimer's s memantine hcl/donepezil hcl NAMZARIC Angioedema treatment ecallantide icatibant acetate FIRAZYR KALBITOR Anti-Cancer s abiraterone acetate olaparib afatinib dimaleate omacetaxine mepesuccinate AFINITOR OPDIVO AFINITOR DISPERZ palbociclib axitinib panobinostat lactate bexarotene pazopanib hcl BOSULIF peginterferon alfa-2b bosutinib pomalidomide cabozantinib s-malate POMALYST CAPRELSA ponatinib hcl ceritinib PURIXAN COMETRIQ regorafenib crizotinib RITUXAN Only your plan can determine coverage of medications. 1
2 Anti-Cancer s dabrafenib mesylate rituximab Continued dasatinib ruxolitinib phosphate enzalutamide sorafenib tosylate ERIVEDGE SPRYCEL erlotinib hcl STIVARGA everolimus sunitinib malate FARYDAK SUTENT GILOTRIF SYLATRON GLEEVEC SYNRIBO HYCAMTIN TAFINLAR IBRANCE TARCEVA ibrutinib TARGRETIN ICLUSIG TASIGNA idelalisib TEMODAR imatinib mesylate TEMOZOLOMIDE IMBRUVICA topotecan hcl INLYTA trametinib dimethyl sulfoxide interferon alfa-2b,recomb. TYKERB INTRON A vandetanib JAKAFI vemurafenib lapatinib ditosylate vismodegib lenvatinib mesylate vorinostat LENVIMA VOTRIENT LYNPARZA XALKORI MEKINIST XTANDI mercaptopurine ZELBORAF NEXAVAR ZOLINZA nilotinib hcl ZYDELIG nivolumab ZYKADIA Anti-Poison s deferasirox FERRIPROX deferiprone JADENU EXJADE Anti-Alcoholic s naltrexone microspheres VIVITROL Anti-Arthritic (Anti-Folate) methotrexate/pf RASUVO OTREXUP Anti-Arthritis s EUFLEXXA hylan g-f 20 GEL-ONE MONOVISC HYALGAN ORTHOVISC hyaluronate sod, cross-linked SUPARTZ hyaluronate sodium SYNVISC hyaluronate sodium, stabilized SYNVISC-ONE Antibiotic aztreonam lysine posaconazole bedaquiline fumarate rifaximin CAYSTON SIRTURO CRESEMBA SPORANOX DIFICID telithromycin fidaxomicin VALCYTE isavuconazonium sulfate VALGANCICLOVIR HCL ITRACONAZOLE VANCOCIN HCL KETEK VANCOMYCIN HCL linezolid VFEND NOXAFIL VORICONAZOLE ONMEL XIFAXAN Only your plan can determine coverage of medications. 2
3 Anticoagulant edoxaban tosylate SAVAYSA Anti-Constipation s methylnaltrexone bromide naloxegol oxalate MOVANTIK RELISTOR Anticonvulsants clobazam SABRIL ONFI vigabatrin Anti-Growth Hormone lanreotide acetate SANDOSTATIN LAR OCTREOTIDE ACETATE SANDOSTATIN LAR DEPOT octreotide acetate, microspheres SIGNIFOR pasireotide diaspartate SIGNIFOR LAR pasireotide pamoate SOMATULINE DEPOT SANDOSTATIN Antihyperlipidemic JUXTAPID lomitapide mesylate (cholesterol) s KYNAMRO mipomersen sodium Anti-Hypertension s enalapril maleate EPANED mecamylamine hcl VECAMYL Anti-Inflammatory anakinra rilonacept (Il-1) Blocker ARCALYST canakinumab/pf KINERET ILARIS Anti-Inflammatory adalimumab HUMIRA (TNF Inhibitor) ENBREL SIMPONI etanercept SIMPONI ARIA golimumab Anti-Inflammatory cyclosporine RESTASIS Immunomodulator (for dry eye) Antileprotic s thalidomide THALOMID Anti-Narcolepsy s armodafinil NUVIGIL MODAFINIL PROVIGIL Anti-Nausea/Vertigo s AKYNZEO netupitant/palonosetron hcl Antiparkinsonism Drug, APOKYN carbidopa/levodopa Other apomorphine hcl DUOPA Antipsychotic ADASUVE loxapine Antiviral palivizumab SYNAGIS Antiviral (Hepatitis C) daclatasvir dihydrochloride peginterferon alfa-2a DAKLINZA peginterferon alfa-2b boceprevir PEGINTRON COPEGUS REBETOL HARVONI RIBAPAK INCIVEK RIBASPHERE INFERGEN RIBATAB interferon alfacon-1 RIBAVIRIN ledipasvir/sofosbuvir simeprevir sodium MODERIBA sofosbuvir OLYSIO SOVALDI ombitasvir/paritaprevir/ritonavir/dasabuvir sodium telaprevir VICTRELIS PEGASYS VIEKIRA PAK Asthma omalizumab XOLAIR Bile Acid Disorder CHOLBAM cholic acid Blood Calcium Reducing cinacalcet hcl SENSIPAR Cancer lenalidomide REVLIMID mechlorethamine hcl VALCHLOR Only your plan can determine coverage of medications. 3
4 COPD DALIRESP roflumilast Cystic Fibrosis dornase alfa KALYDECO ivacaftor PULMOZYME Diabetic Ulcer / becaplermin REGRANEX Wound Diuretic SAMSCA tolvaptan Enzyme Joint Therapy COLLAGENASE CLOSTRIDIUM HISTOLYTICUM XIAFLEX Enzyme s (Eye) JETREA ocriplasmin/pf Enzyme Replacement CEREZYME taliglucerase alfa (Gaucher's) ELELYSO velaglucerase alfa imiglucerase VPRIV Erectile Dysfunction alprostadil sildenafil citrate avanafil STAXYN CAVERJECT STENDRA CIALIS tadalafil EDEX vardenafil hcl LEVITRA VIAGRA MUSE Gaucher's CERDELGA miglustat eliglustat tartrate ZAVESCA Gout KRYSTEXXA pegloticase Growth Factor INCRELEX mecasermin Growth Hormone GENOTROPIN OMNITROPE HUMATROPE SAIZEN NORDITROPIN FLEXPRO SEROSTIM NORDITROPIN NORDIFLEX somatropin NUTROPIN TEV-TROPIN NUTROPIN AQ ZOMACTON NUTROPIN AQ NUSPIN ZORBTIVE Growth Hormone EGRIFTA tesamorelin acetate (For Excess Fat Loss) Growth Hormone Blocking pegvisomant SOMAVERT Heart Failure CORLANOR ivabradine hcl Hormone (Androgenic) ANDRODERM NATESTO ANDROGEL STRIANT ANDROID TESTIM ANDROXY TESTONE CIK AVEED TESTOPEL AXIRON TESTOSTERONE DELATESTRYL TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE TESTOSTERONE ENANTHATE fluoxymesterone testosterone undecanoate FORTESTA TESTRED METHITEST VOGELXO methyltestosterone Hormone (Female) hydroxyprogesterone caproate MAKENA KORLYM mifepristone Huntington's Disease tetrabenazine XENAZINE Immunosuppressive everolimus ZORTRESS Inflammatory certolizumab pegol infliximab (TNF Alpha Inhibitor) CIMZIA REMICADE Irritable Bowel Syndrome ALOSETRON HCL LOTRONEX Only your plan can determine coverage of medications. 4
5 Lipodystrophy metreleptin MYALEPT (Low Body Fat) Multiple Sclerosis / Crohn's natalizumab TYSABRI Multiple Sclerosis alemtuzumab glatiramer acetate AMPYRA GLATOPA AUBAGIO interferon beta-1a AVONEX interferon beta-1a/albumin human BETASERON interferon beta-1b COPAXONE LEMTRADA dalfampridine peginterferon beta-1a dimethyl fumarate PLEGRIDY EXTAVIA REBIF fingolimod hcl GILENYA TECFIDERA teriflunomide Narcolepsy sodium oxybate XYREM Narcotic Withdrawal BUNAVAIL BUPRENORPHINE-NALOXONE BUPRENORPHINE HCL SUBOXONE buprenorphine hcl/naloxone hcl ZUBSOLV Neuromuscular Blocking abobotulinumtoxina MYOBLOC s BOTOX onabotulinumtoxina DYSPORT rimabotulinumtoxinb incobotulinumtoxina XEOMIN Non-24-Hour Sleep-Wake HETLIOZ tasimelteon Disorder NSAID diclofenac epolamine DICLOFENAC SODIUM FLECTOR SOLARAZE Orthostatic Hypotension droxidopa NORTHERA (NOH) Osteoporosis denosumab teriparatide FORTEO XGEVA PROLIA Pain (Narcotic) ABSTRAL hydrocodone bitartrate ACTIQ HYSINGLA ER buprenorphine LAZANDA BUTRANS ONSOLIS fentanyl SUBSYS FENTANYL CITRATE ZOHYDRO ER FENTORA Pain (NSAID/PPI) naproxen/esomeprazole magnesium VIMOVO Parathyroid Hormone NATPARA parathyroid hormone PCSK9 Inhibitors alirocumab PRALUENT (Cholesterol-Lowering) Pituitary Hormone corticotropin H.P. ACTHAR Platelet Production eltrombopag olamine oprelvekin Stimulator NEUMEGA PROMACTA NPLATE romiplostim PseudoBulbar Affect (PBA) dextromethorphan hbr/quinidine sulfate NUEDEXTA Psoriasis apremilast secukinumab COSENTYX STELARA OTEZLA ustekinumab Only your plan can determine coverage of medications. 5
6 Pulmonary Fibrosis ESBRIET OFEV nintedanib esylate pirfenidone Pulmonary Hypertension ADCIRCA REMODULIN ADEMPAS REVATIO ambrisentan riociguat bosentan SILDENAFIL EPOPROSTENOL SODIUM sildenafil citrate epoprostenol sodium (arginine) tadalafil epoprostenol sodium (glycine) TRACLEER FLOLAN treprostinil iloprost tromethamine treprostinil diolamine LETAIRIS treprostinil sodium Pulmonary Hypertension macitentan TYVASO opsumit ORENITRAM ER VELETRI VENTAVIS Red blood Cell Stimulant ARANESP methoxy polyethylene glycol-epoetin beta darbepoetin alfa in polysorbate 80 MIRCERA epoetin alfa PROCRIT EPOGEN Rheumatoid Arthritis abatacept tocilizumab ACTEMRA tofacitinib citrate ORENCIA XELJANZ Rosacea s brimonidine tartrate MIRVASO ivermectin SOOLANTRA Short Bowel Syndrome GATTEX teduglutide Smoking Deterrent CHANTIX varenicline tartrate Stem Cell Transplantation MOZOBIL plerixafor Topical ELIDEL PROTOPIC Immunosuppressive pimecrolimus TACROLIMUS s Weight Loss ADIPEX-P naltrexone hcl/bupropion hcl BELVIQ orlistat BENZPHETAMINE HCL PHENDIMETRAZINE TARTRATE BONTRIL PDM PHENTERMINE HCL CONTRAVE phentermine hcl/topiramate DIDREX QSYMIA DIETHYLPROPION HCL REGIMEX DIETHYLPROPION HCL ER SAXENDA liraglutide SUPRENZA ODT lorcaserin hcl XENICAL White Blood Cell Stimulant filgrastim NEUPOGEN GRANIX pegfilgrastim LEUKINE sargramostim NEULASTA tbo-filgrastim 2550 University Ave. West Suite 320N St. Paul, MN Only your plan can determine coverage of medications. 6
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