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DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll-free at 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization, please use a Prior Authorization form which can be obtained from ConnectiCare.com or by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate). Note: Self-administered medications (i.e. interferons), even those not on this list, may not be dispensed for self administration and billed through the medical benefit by a provider. They must be dispensed through a participating pharmacy. (*) prior authorization is not required within the first 90 days of membership with ConnectiCare. (M) physician-administered drug, usually billed under the medical benefit. The information in this document does not apply to members with ConnectiCare VIP Medicare Plans, ConnectiCare Exchange Plans and most of ConnectiCare® SOLO Plans. To find a drug, click on a letter and browse the table alphabetically. A•B•C•D•E•F•G•H•I•J•K•L•M•N•O•P•Q•R•S•T•U•V•W•X•Y•Z Or, click this Search MEDICATION button and enter the name of the drug in the pop-up task pane. COMMENTS *Abilify/Maintena Absorica Abstral Aciphex/generic rabeprazole (Use OTC PPI first) Actemra Acthar Gel Actiq/generic fentanyl lozenge *Actonel (Use alendronate first) *ActoplusMet XR (Use metformin first) M Adcetris Adcirca *Adempas *Adoxa (Use generics first) Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 1 of 17 Please note: If the Search button does not work in the browser you are using, use the search feature within your web browser. DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Afinitor Afrezza M Aldurazyme M Alimta AlleRx (Use Allegra, Zyrtec, and Claritin OTC first—covered) Alsuma *Altoprev (Use simva-, prava-, lovastatin first) *Ambien CR/generic zolpidem ER (Use Ambien) Amevive Ampyra Amrix/generic cyclobenzaprine ER (Use older generics first) *Amturnide (Use generic ACE or ARB first) Androderm Androgel Antara Anzemet (Use ondansetron first) Apidra Aplenzin (Use generic bupropion hcl) Apokyn M Aralast M Arcalyst Aricept 23 Arnuity Ellipta Arthrotec M Arzerra Ascensia Test Strips (Use Accuchek or Freestyle) *Astepro Nasal Spray/generic azelastine 0.15% (Use Astelin) *Atelvia (Use alendronate) Aubagio Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 2 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS *Avandamet (Use metformin first) *Avandaryl (Use metformin first) *Avandia (Use metformin first) M (PA not required for use in the eye) Avastin Aveed injection Avidoxy (Use generic first) Avodart Avonex *Axert (Use generic triptan first) Axiron *Azor (Use generic ACE or ARB first) *Beconase AQ (Use generic Flonase first) Belsomra *Benicar/Benicar HCT M (Use generic ACE or ARB first) Benlysta Berinert Betaseron M Bexxar *Binosto M Blood Clotting Factors (All) Boniva Injection Bosulif Botox Bravelle Breo Ellipta *Brintellix *Brisdelle Brovana Buphenyl Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 3 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS *Bydureon *Byetta (Use metformin first) Cambia Campral/generic acamprosate Caprelsa Cayston *Celebrex M Cerdelga M Cerezyme Cesamet Cetrotide Cimzia Cinryze Clarinex/Clarinex D/generic desloratadine (Use Allegra, Zyrtec, and Claritin OTC first—covered) Clobex Lotion (Use generic clobetasol first) Clolar Clomid/generic clomiphene CNL Nail Kit Coartem Cometriq Compounded Medications Contraceptives (if excluded by group) Copaxone *Coreg CR (Use carvedilol first) *Crestor Crinone Cuvposa Cyramza M Dacogen Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 4 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS *Daliresp *Desvenlafaxne Fumarate *Detrol/Detrol LA/generic tolterodine (Use oxybutynin IR/XL first) Dexilant (Use OTC Prevacid or Prilosec 1st) *Differin 0.3% (Use 0.1% first) Dificid *Doryx (Use generics first) Dovonex *Duetact (Use metformin first) Duexis Dymista Dysport Ecoza *Edarbi *Edarbyclor *Edluar (Use zolpidem generic tablets) Egrifta M Elaprase Elelyso M Eloxatin (Use oxybutynin IR/XL first) *Enablex Enbrel Endometrin Entyvio Epanova Epinephrine Auto-Injector M Erbitux Erivedge Esomeprazole Strontium Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 5 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION M COMMENTS Euflexxa Evzio *Exalgo (#14 allowed, use formulary agent first) *Exelon patch *Exforge/Exforge HCT (Use generic ACE or ARB first) Exjade Extavia M Fabrazyme *Fanapt *Farxiga Fenoglide Fentora *Fetzima Fexmid Fibrocor Firazyr Flector Patch M Flolan/epoprostenol Fluoxetine 60mg Follistim AQ Folotyn Fortamet (Use generic metformin first) Fortesta Forfivo XL Fosamax Solution (Use alendronate) *Frova (Use generic triptan first) Fuzeon Ganirelix Gastrocrom Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 6 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Gattex Gazyva *Gelnique M Gel-One Genotropin Gilenya Gilotrif Glassia Gleevec Glumetza (Use generic metformin first) Gonal-F Gralise Grastek Growth Hormones (All) M Halaven HCG (chorionic gonadotropin) M Herceptin Hetlioz M Hizentra Horizant Humatrope Humira M Hyalgan Hycamtin Capsules Iclusig Ilaris Imbruvica Impavido Implanon Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 7 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Increlex Inderal XL Infertility Medications (All) Injectable Drugs – All (excluding insulin) Inlyta Intermezzo Intron-A *Intuniv *Invega/Sustenna *Invokana (Use metformin first) *Invokamet M Istodax M IV Immune Globulin (IVIG) M Ixempra Jakafi *Jardiance Μ Jevtana Jublia Juxtapid M Kadcyla M Kalbitor Kalydeco Karbinal ER Kazano (Use metformin and Sitagliptin or Linagliptin first) Kerydin M Keytruda *Khedezla Kineret Klonopin Wafers/generic clonazepam wafers (Use clonazepam tablets) Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 8 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS *Kombiglyze XR (Use metformin and Sitagliptin or Linagliptin first) Korlym M Krystexxa Kuvan Kynamro M Kyprolis Kytril/generic granisetron (Use generic Zofran first) Lamictal ODT *Lamictal XR/generic lamotrigine ER *Latuda Lazanda *Lescol/XL (Use generic statin first) Letairis Liptruzet Livalo Lofibra Lotronex Lovaza/generic Omega 3 acid ethyl esters Lumigan Lumizyme *Lunesta/generic eszopiclone (Use generic Ambien) Luveris *Luvox CR (Use generics first) *Luxiq (Use generic betamethasone first) Luzu *Lyrica M Macugen Makena Marinol/generic dronabinol Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 9 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Marqibo Mekinist Menopur Mepron/generic atovaquone Metozolv (Use generic first) M (PA on pharmacy side only) Mirena Monovisc M Mozobil M Myobloc M Myozyme *Myrbetriq M Naglazyme Namenda (PA < 50 years old only) Naprelan *Nasarel (Use fluticasone or Nasonex) Natesto Nesina (Use metformin and Sitagliptin or Linagliptin first) Nexavar Nexium (Use OTC PPI’s first) Nexplanon PA not required under medical benefit Nimotop Norditropin Novarel Novolin/Novolog M Novoseven M Nplate Nuedexta M Nulojix Nutropin/AQ Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 10 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Nuvigil Oforta Oleptro Olux (Use generic clobetasol first) Olux-E Olysio *Omnaris (Use fluticasone or Nasonex) Omnitrope Omtryg One Touch Test Strips (Use Accuchek or Freestyle) Onglyza (Use metformin and Sitagliptin or Linagliptin first) Onsolis Opana ER (crush resistant formulation) *Opsumit *Oracea Oralair Oravig M Orencia/Orencia SQ Orfadin M Orthovisc Oseni (Use metformin and Sitagliptin or Linagliptin first) Otezla Otrexup Ovidrel *Oxtellar XR Oxycodone AG (Oxycontin Authorized Generic) *Oxytrol (Use generic oxybutynin IR/XL first) Ozurdex Patanase (Use Astelin first) Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 11 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Pegasys Peg-Intron Pennsaid M Perjeta *Pexeva (Use generics first) Plegridy Pomalyst Ponstel/generic mefenamic acid (Use generic NSAIDs) Prevacid (Use Prevacid OTC—Tier 1) M Prialt Prilosec (Use Prilosec OTC—Tier 1) *Pristiq (Use venlafaxine first) Prolastin M Proleukin Prolia Promacta Procysbi Protonix M (Use Prilosec OTC) Provenge Provigil/generic modafinil *Prozac Weekly (Use generics first) Qudexy XR *Qnasl Qualaquin Qutenza Ragwitek *Rapaflo (Use Flomax first) *Rayos Ravicti Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 12 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Rebif Regranex Relistor *Relpax M Remicade M Remodulin (Use generic triptan first) Repronex M Retisert Revatio/generic sildenafil Revlimid M RiaSTAP Ribavirin (Ribapak) *Risperdal Consta M Rituxan Ruconest Saizen *Sanctura (Use oxybutynin IR/XL first) Sancuso (Use ondansetron first) *Saphris *Sarafem (Use generics first) Signifor Silenor Simponi/Simponi ARIA M Skyla (PA on pharmacy side only) Solodyn M Soliris Somavert Sorilux Foam Sovaldi Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 13 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Sporanox/generic itraconazole Sprix Nasal spray Sprycel *Stavzor (Use generic first) Stelara Stivarga *Strattera Striant Subsys Sucraid Sumavel Dosepro M Supartz Supprelin LA Sutent Sylatron Sylvant *Symlin M Synagis Synarel Synribo M Synvisc Tafinlar *Tanzeum Tarceva Tasigna Tecfidera *Tekamlo (Use generic ACE or ARB first) *Tekturna (Use generic ACE or ARB first) Temodar/generic temozolomide Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 14 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION COMMENTS Testim/generic testosterone transdermal gel Testosterone (All) *Tevetan HCT (Use generic ACE or ARB first) TevTropin Thalomid Thyrogen Tivorbex M Torisel *Toviaz (Use oxybutynin IR/XL first) Tracleer Travatan/Travatan Z Travel Medication: i.e. Malarone M Treanda Tretin-X (Use tretinoin first) Treximet (Use sumatriptan with naproxen) *Tribenzor (Use generic ACE or ARB first) Triglide Trokendi XR Trospium (Use oxybutynin IR/XL first) Tykerb Tysabri Tyvaso *Uloric (Use allopurinol first) Ultram ER/generic tramadol ER (Use immediate release generic) Valchlor *Valturna (Use generic ACE or ARB first) Vanos Vantas Vascepa Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 15 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION M Vectibix M Velcade COMMENTS Velphoro Venlafaxine Extended Release Tabs M (Use generics first) Ventavis Verdeso (Use generic desonide first) *Versacloz *Vesicare (Use oxybutynin IR/XL first) *Victoza (Use metformin first) Victrelis M Vidaza *Viibryd Vimizim Vimovo M Vivitrol Vogelxo Voltaren Gel Votrient M Vpriv Vusion *Vytorin (Use simva-, prava-, lovastatin first) Weight Loss Medication (if covered by your plan) *Welchol Xalkori Xartemis XR Xeljanz Xeloda/generic capecitabine Xenazine M Xeomin Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 16 of 17 DRUG PRIOR AUTHORIZATION LIST This list does not apply to members of ConnectiCare Exchange Plans and most ConnectiCare® SOLO Plans using the Freedom Drug List. MEDICATION M Xgeva M Xiaflex COMMENTS Ximino Xofigo Xolair Xtandi M Xyntha Xyrem M Yervoy M Zaltrap Zavesca Zecuity Zegerid (PA for > 15 y/o) (Use OTC or OTC Prevacid/Prilosec) Zelboraf M Zemaira *Zetonna Zipsor (Use diclofenac tablets) Zohydro ER Zolinza Zolpimist (Use generic zolpidem tablets) Zontivity Zortress Zorvolex Zuplenz Zyban (Use bupropion) Zydelig Zyflo CR (Use Singulair first) Zykadia Zytiga Back to Top Drug Prior Authorization List | Effective Oct 2014 Page 17 of 17