Special Authorization
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- Julian Lenard Nicholson
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1 Special Authorization Certain medications in the Reformulary require Special Authorization from your insurance company before your prescription is eligible for coverage. What is Special Authorization? Your drug plan provides you with immediate access to about 10,000 prescription drugs. Certain other medications require Special Authorization before your prescription is eligible for coverage. Will I need to pay for my prescription myself? If the Special Authorization is approved, you will pay the lowest amount (copay) available in your plan for your prescription. If the Special Authorization is not approved, you may need to pay the full price of the prescription yourself. How do I apply for Special Authorization? Your doctor needs to provide a well-documented medical reason why you need to take the Special Authorization drug. Here s how you apply: 1. Complete the Special Authorization (SA) form; you can download the Special Authorization form from your plan administrator s website. Both you and your doctor will need to complete the form. Have your doctor or pharmacist call or fax the Special Authorization (SA) form to your plan administrator. 2. Once your request has been processed, you will be notified and you will also receive a letter in the mail. You will need to have the Special Authorization request approved to pay the lowest amount (co-pay) in your plan. 3. If your plan administrator needs more information, they may contact your doctor directly. 4. If the request is approved, have your prescription filled. If the special authorization request is denied, you and your doctor will be notified. Clinical Conditions in the Reformulary Special Authorization Drugs December
2 What happens to my Special Authorization request once it is sent to my plan administrator? Your request will be confidentially reviewed by a qualified medical reviewer, according to specific criteria. You will receive written notification of the decision, typically within seven to fourteen working days. In cases where a doctor requires an urgent response due to the medical condition, every effort will be made to respond promptly. If your request is approved, the approval will indicate the specified period of time. You will likely need to re-apply for Special Authorization after that specified time period. What if I am already taking a Special Authorization drug? If you are already taking a Special Authorization drug when your new drug plan launches, your drug will be grandfathered. This means that you may continue taking this drug at the lowest amount (co-pay). Please refer to Clinical Conditions in the Reformulary Grandfathered Drugs for more information. Any statement suggesting that you consider a particular drug, indicating that any drug is a preferred drug, or describing the effectiveness of a drug is not intended to be a substitute for your physician's advice, diagnosis or treatment, and should not be used to replace a health care professional, for diagnosis or for treatment. You should not act or rely on any Information provided in this document or in DrugFinder at without seeking the advice of a physician or health care professional. Clinical Conditions in the Reformulary Special Authorization Drugs December
3 ACTEMRA (tocilizumab) ADCIRCA (tadalafil) adefovir ADEMPAS (riociguat) AFINITOR, AFINITOR DISPERZ (everolimus) Rheumatoid Arthritis (RA); Juvenile Idiopathic Arthritis (JIA) Hepatitis B ALDURAZYME (laronidase) Mucopolysaccharidosis I (MPS I) APTIOM (eslicarbazepine) APTIVUS (tipranavir) ARANESP (darbepoetin alfa) AUBAGIO (teriflunomide) AVANDIA (rosiglitazone), AVANDAMET (rosiglitazone/metformin) AVONEX (interferon beta-1a) BANZEL (rufinamide) BENLYSTA (belimumab) BETASERON (interferon beta-1b) bosentan BOSULIF (bosutinib) BOTOX (onabotulinumtoxin A) butorphanol nasal spray Epilepsy HIV/AIDS Anemia Diabetes ++ Epilepsy Lupus Miscellaneous Migraines CALCIJEX (calcitriol) Kidney Disease ++ calcitriol (injectable) Kidney Disease ++ CAPRELSA (vandetanib) CARIPUL (epoprostenol) Clinical Conditions in the Reformulary Special Authorization Drugs December
4 CAYSTON (aztreonam) CELSENTRI (maraviroc) CEREZYME (imiglucerase) Chlorax (clidinium bromide + chlordiazepoxide hydrochloride) CIMZIA (certolizumab) COPAXONE (glatiramer) COSENTYX (secukinumab) CYSTADANE (betaine) DAXAS (roflumilast) DIACOMIT (stiripentol) DIFICID (fidaxomicin) DUODOPA (carbidopa + levodopa) ELAPRASE (idursulfase) ELELYSO (taliglucerase alfa) ENBREL (etanercept) ENTOCORT (budesonide) ENTYVIO (vedolizumab) EPREX (epoetin alfa) ERIVEDGE (vismodegib) erlotinib ESBRIET (pirfenidone) EXJADE (deferasirox) EXTAVIA (interferon beta-1b) Cystic Fibrosis HIV/AIDS Gaucher's Disease Gastrointestinal (GI) Disorders ++ Rheumatoid Arthritis (RA); Psoriatic Arthritis; Ankylosing Spondylitis Psoriasis Homocystinuria Asthma, COPD Epilepsy Parkinson s Disease Hunter syndrome Gaucher's Disease Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; Juvenile Idiopathic Arthritis (JIA); Ankylosing Spondylitis IBD (Crohn s Disease & Ulcerative Colitis) IBD (Crohn s Disease & Ulcerative Colitis) Anemia Idiopathic Pulmonary Fibrosis Chronic Iron Overload Clinical Conditions in the Reformulary Special Authorization Drugs December
5 EYLEA (aflibercept) FABRAZYME (agalsidase beta) FAMPYRA (fampridine) FERRIPROX (deferiprone) FIRAZYR (icatibant) FLOLAN (epoprostenol) FLUDARA (fludarabine) FORTEO (teriparatide) FOSRENOL (lanthanum carbonate hydrate) FUZEON (enfuvirtide) FYCOMPA (perampanel) GALEXOS (simeprevir) GENOTROPIN (somatropin) GILENYA (fingolimod) GIOTRIF (afatinib) GLEEVEC (imatinib) HARVONI (ledipasvir + sofosbuvir) HEPSERA (adefovir) HOLKIRA PAK (ritonavir + paritaprevir + ombitasvir + dasabuvir) HUMATROPE (somatropin) HUMIRA (adalimumab) ICLUSIG (ponatinib) ILARIS (canakinumab) Fabry Disease Iron Overload Hereditary Antioedema (HAE) Osteoporosis Hyperkalemia; Hyperphosphatemia HIV/AIDS Epilepsy Hepatitis B Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; IBD (Crohn s Disease & Ulcerative Colitis); Juvenile Idiopathic Arthritis (JIA); Ankylosing Spondylitis Juvenile Idiopathic Arthritis (JIA); Cryopyrin- Associated Periodic Syndrome (CAPS) Clinical Conditions in the Reformulary Special Authorization Drugs December
6 imatinib IMBRUVICA (ibrutinib) IMUNOVIR (inosine) ++ INCIVEK (telaprevir) Inflectra (infliximab) INLYTA (axitinib) IRESSA (gefitinib) JAKAVI (ruxolitinib) JETREA (ocriplasmin) JINARC (tolvaptan) JUXTAPID (lomitapide) KALYDECO (ivacaftor) KINERET (anakinra) KUVAN (sapropterin) LEMTRADA (alemtuzumab) LIBRAX (clidinium bromide + chlordiazepoxide hydrochloride) linezolid LUCENTIS (ranibizumab) MACUGEN (pegaptanib) MEKINIST (trametinib) METOJECT (methotrexate) Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; Ankylosing Spondylitis Autosomal Dominant Polycystic Kidney Disease (ADPKD) Homozygous familial hypercholesterolemia (HoFH) Cystic Fibrosis Rheumatoid Arthritis (RA); Juvenile Idiopathic Arthritis (JIA) Phenylketonuria Gastrointestinal (GI) Disorders ++ Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; IBD (Crohn s Disease & Ulcerative Colitis) MULTAQ (dronedarone) Heart and Blood Pressure ++ MYOZYME (alglucosidase) Pompe's Disease Clinical Conditions in the Reformulary Special Authorization Drugs December
7 NAGLAZYME (galsulfase) NEULASTA (pegfilgrastim) NEUPOGEN (filgrastim) NEUPRO (rotigotine) NEXAVAR (sorafenib) NORDITROPIN NORDIFLEX (somatropin) NPLATE (romiplostim) NUTROPIN AQ (somatropin) Omnitrope (somatropin) OPSUMIT (macitentan) ORENCIA (abatacept) OTEZLA (apremilast) OZURDEX (dexamethasone) POMALYST (pomalidomide) POSANOL (posaconazole) PROLASTIN-C (alpha 1-proteinase inhibitor) PULMOZYME (dornase alfa) RASILEZ (aliskiren), RASILEZ HCT (aliskiren/hydrochlorothiazide) REBIF (interferon beta-1a) REMICADE (infliximab) REMODULIN (treprostinil) RENAGEL (sevelamer hydrochloride) RENVELA (sevelamer carbonate) Mucopolysaccharidosis VI (MPS VI, Maroteaux- Lamy syndrome) -related Conditions -related Conditions Parkinson s Disease Refractory chronic immune thrombocytopenia purpura (ITP) Rheumatoid Arthritis (RA); Juvenile Idiopathic Arthritis (JIA) Psoriasis Eye/Ear Inflammation Congenital Alpha 1-Antitrypsin Deficiency Cystic Fibrosis Heart and Blood Pressure ++ Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; IBD (Crohn s Disease & Ulcerative Colitis); Juvenile Idiopathic Arthritis (JIA); Ankylosing Spondylitis Hyperkalemia; Hyperphosphatemia Hyperkalemia; Hyperphosphatemia Clinical Conditions in the Reformulary Special Authorization Drugs December
8 RESTASIS (ciclosporin) RETISERT (fluocinolone) REVATIO (sildenafil) REVLIMID (lenalidomide) REVOLADE (eltrombopag) RILUTEK (riluzole) riluzole RITUXAN (rituximab) SAIZEN (somatropin) SAMSCA (tolvaptan) SAPHRIS (asenapine) SATIVEX (cannabidiol + delta-9- tetrahydrocannabinol) SEBIVO (telbivudine) SENSIPAR (cinacalcet) SIGNIFOR (pasireotide) sildenafil (20 mg) SIMPONI (golimumab) SIMPONI I.V. (golimumab) SOLIRIS (eculizumab) SOMAVERT (pegvisomant) SOVALDI (sofosbuvir) SPRYCEL (dasatinib) Dry Eye ; Refractory chronic immune thrombocytopenia purpura (ITP) Amyotropic Lateral Sclerosis (ALS) Amyotropic Lateral Sclerosis (ALS) Rheumatoid Arthritis (RA); Juvenile Idiopathic Arthritis (JIA) Hyponatremia Bipolar Disorder Pain Hepatitis B CKD (with hyperparathyroidism); Hypercalcemia (primary hyperparathyroidism); Hypercalcemia (with parathyroid carcinoma) Cushing's Disease Rheumatoid Arthritis; Psoriatic Arthritis; IBD (Crohn s Disease & Ulcerative Colitis); Ankylosing Spondylitis Rheumatoid Arthritis Hemolytic uremic syndrome (HUS); Paroxysmal nocturnal hemoglobinuria (PNH) Acromegaly Clinical Conditions in the Reformulary Special Authorization Drugs December
9 STELARA (ustekinumab) STIVARGA (regorafenib) SUTENT (sunitinib) tadalafil TAFINLAR (dabrafenib) TARCEVA (erlotinib) TASIGNA (nilotinib) TECFIDERA (dimethyl) TEMODAL (temozolomide) temozolomide THALOMID (thalidomide) TOBI, TOBI PODHALER (tobramycin) TRACLEER (bosentan) TYKERB (lapatinib) TYSABRI (natalizumab) ULORIC (febuxostat) VFEND (voriconazole) VICTRELIS (boceprovir) VICTRELIS TRIPLE (boceprevir + peginterferon Alfa- 2B + ribavirin) VIMIZIM (elosulfase alfa) VISUDYNE (verteporfin) VOLIBRIS (ambrisentan) voriconazole (injectable) VOTRIENT (pazopanib) VPRIV (velaglucerase alfa) Psoriasis; Psoriatic Arthritis Cystic Fibrosis Gout Mucopolysaccharidosis IVA (MPS IVA) Gaucher's Disease Clinical Conditions in the Reformulary Special Authorization Drugs December
10 XALKORI (crizotinib) XELJANZ (tofacitinib) XEOMIN (incobotulinumtoxin A) XIAFLEX (collagenase clostridium histolyticum) XOLAIR (omalizumab) XTANDI (enzalutamide) ZAVESCA (miglustat) ZAXINE (rifaximin) ZELBORAF (vemurafenib) ZOLINZA (vorinostat) ZYDELIG (idelalisib) ZYKADIA (ceritinib) ZYTIGA (abiraterone acetate) ZYVOXAM (linezolid) Rheumatoid Arthritis Miscellaneous Dupuytren's contracture Asthma, COPD Gaucher's Disease; Niemann-Pick Disease Type C Hepatic Encephalopathy BRAND drugs are capitalized. Generic drugs are in italics. Symbol denotes grandfathered drugs. Please refer to Clinical Conditions in the Reformulary Grandfathered Drugs for more information ++ Only plan members already taking these drugs may continue to receive coverage for these drugs. Special Authorization will not be given to plan members with a new prescription due to clinical concerns. Clinical Conditions in the Reformulary Special Authorization Drugs December
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