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Prior authorization helps ensure that covered medications provide the best safety and value. It
is needed when a medication has only been proven to benefit a limited number of people or if
unusually large doses are requested for coverage.
These medications require prior authorization Possible alternatives
because alternatives may offer a better value
Cholesterol
atorvastatin, Crestor®
simvastin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®)
simvastin (Zocor®), pravastatin (Pravachol®), lovastatin
Depression
bupropion SR (Wellbutrin SR®), bupropion XL 300mg (Wellbutrin
XL®), fluoxetine (Prozac®), fluvoxamine maleate, mirtazapine
(Remeron®), paroxetine (Paxil®), sertraline (Zoloft®)
Diabetes
ACTOplus Met™, Actos®, Avandamet®, Avandaryl™, metformin
(Glucophage®), glimepiride (Amaryl®), glipizide
(Glucotrol®), glyburide (Diabeta®), insulin
Kombiglyze™ XR, Onglyza™, Tradjenta™, Victoza®
High Blood Pressure
benazepril/HCT (Lotensin/HCT®), captopril/HCT (Capoten/
Benicar®, Benicar HCT®, Micardis®, Micardis HCT® Captozide®), enalapril/HCT (Vasotec/Vaseretic®), fosinopril/
HCT (Monopril/HCT®), lisinopril/HCT (Zestril/Zestoretic®,
Prinivil/Prinzide®), losartan/HCT (Cozaar/Hyzaar®), moexipril/
HCT (Univasc/Uniretic®), quinapril/HCT (Accupril/Accuretic®),
trandolapril (Mavik®)
Amturnide™, Atacand®, Atacand-HCT®, Avalide®, benazepril/HCT (Lotensin/HCT®), captopril/HCT(Capoten/
Avapro®, Azor®, Diovan®, Diovan HCT®, Edarbi™, Captozide®), enalapril/HCT (Vasotec/Vaseretic®), fosinopril/
Exforge®, Exforge HCT®, Tekamlo™, Tekturna®, Tekturna HCT (Monopril/HCT®), lisinopril/HCT (Zestril/Zestoretic®, Prinivil/
HCT®, Teveten®, Teveten HCT®, Tribenzor™, Twynsta®, Prinzide®), losartan/HCT (Cozaar/Hyzaar®), moexipril/HCT (Univasc/
Uniretic®), quinapril/HCT (Accupril/Accuretic®), trandolapril
(Mavik®), Benicar®, Benicar HCT®, Micardis®, Micardis HCT® Mental Health
clozapine
Abilify®, Fanapt®, Geodon®, Invega®, Latuda®, Saphris®, (Clozaril®), olanzapine (Zyprexa®), risperidone
ziprasidone
Migraines
sumatriptan (Imitrex®)
Alsuma™, Amerge®, Axert®, Frova®, naratriptan HCL,
Sumavel™ DosePro™, Treximet™, Zomig®, Zomig-ZMT® sumatriptan (Imitrex®), Maxalt®, Maxalt-MLT®, Relpax®
Multiple Sclerosis
Nasal Steroids
flunisolide
Beconase AQ®, Nasonex®, Omnaris®, Qnasl™, Rhinocort (Nasalide®), fluticasone (Flonase®), triamcinolone
acetonide
Pain and Inflammation
Generic non-steroidal anti-inflammatory medications (NSAIDs) such as: diclofenac (Voltaren®), etodolac (Lodine®), flurbiprofen
(Ansaid®), ibuprofen (Motrin®), indomethacin (Indocin®),
ketoprofen (Orudis®), nabumetone (Relafen®), naproxen
(Naprosyn®), oxaprozin (Daypro®), piroxicam (Feldene®), salsalate
(Disalcid®), sulindac (Clinoril®), tolmetin (Tolectin®)
Stomach Acid
lansoprazole, pantoprazole, Dexilant™, Kapidex™
omeprazole (Prilosec®)
Aciphex®, Nexium®, Prevacid®, Protonix®, Vimovo™ omeprazole (Prilosec®), Dexilant™, Kapidex™
Effective 04/12NOTE: Our medication Prior Authorization List is subject to change. If the requested medication is authorized, there maybe limits to the amount of medication that is eligible for coverage. Please call our Customer Service Department if you have any questions. The Bottom Line – Safety is our top priority and our prior authorization program helps you and your doctors
choose quality medications that provide the most value. Some alternatives might also help you save money.
These medications require prior authorization
Maximum quantity per month
if prescribed above the maximum quantity
unless otherwise specified
Imitrex® (sumatriptan succinate) injection 10 discs (2 treatment courses) per 6 months 40 capsules (2 treatment courses) per 6 months 20 capsules (2 treatment courses) per 6 months These medications require prior authorization to determine if they can be covered
for your medical condition
NOTE: In addition to the above medications, there are limits to the amount of medication eligible for coverage for all prescriptions. These limits are based on your prescription benefit along with information from the FDA and scientific literature about maximum, safe, effective

Source: http://www.csd509j.net/Portals/1/Business%20Services/Insurance%20Benefits/2012-13/Certified/13%20Rx%20Prior%20Authorization.pdf