|
Medication Name
|
Description
|
| Accolate (Asthma) |
Step therapy. For treatment of allergic rhinitis, members greater than 18 years of age must try a nasal steroid and a non-sedating antihistamine. |
| Aciphex (Gastrointestinal) |
Step therapy. Member must first try/fail 2 generic Proton Pump Inhibitors. |
| Actemra (Rheumatoid Arthritis) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Actiq (Pain) |
Prior Authorization. For the treatment of cancer-related pain. |
| Adcirca (Pulmonary Hypertension) |
Prior authorization. For the treatment of Pulmonary Arterial Hypertension. |
| Ambien CR (Sleep Aid) |
Step therapy. Member must try zolpidem (generic Ambien) or zaleplon (generic Sonata) first. |
| Amerge (Migraine) |
Step Therapy. Member must first try sumatriptan or Imitrex. |
| Amitiza (Gastrointestinal) |
Prior authorization. For the treatment of chronic constipation or irritable bowel syndrome (IBS) in women 18 years of age or older who have tried or unable to tolerate other laxatives. |
| Antara (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Atralin (Acne) |
Prior authorization. If over the age of 35, approval will not be given for treatment of cosmetic conditions; e.g., sunspots or wrinkles. |
| Avastin (Cancer) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Avita (Acne) |
Prior authorization. If over the age of 35, approval will not be given for treatment of cosmetic conditions; e.g., sunspots or wrinkles. |
| Avonex (Multiple Sclerosis) |
Prior authorization. For the treatment of patients with relapsing forms of multiple sclerosis. |
| Axert (Migraine) |
Step Therapy. Member must first try sumatriptan or Imitrex. |
| Banzel (Seizures) |
Prior authorization. For the treatment of Lennox-Gastaut Syndrome. |
| Betaseron (Multiple Sclerosis) |
Prior authorization. For the treatment of patients with relapsing forms of multiple sclerosis. |
| Botox (Cervical Dystonia) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Bupropion SR (Antidepressant) |
If using for smoking cessation, refer to your Benefits Certificate, Coverage Manual or Policy. |
| Bupropion XL (Antidepressant) |
If using for smoking cessation, refer to your Benefits Certificate, Coverage Manual or Policy. |
| Byetta (Diabetes) |
For the treatment of Type 2 Diabetes when other drugs to treat diabetes have been tried and/or have failed. |
| CNL8 NAIL KIT (Antifungal) |
Prior authorization. Physician must provide documentation that oral alternatives are not appropriate. |
| CNL8 NAIL KIT (Antifungal) |
Prior authorization. Physician must provide documentation that oral alternatives are not appropriate. |
| Celebrex (Anti-Inflammatory) |
Prior authorization required if under age 60. Documentation must demonstrate failure of traditional NSAID and PPI therapy in the last 12 months. Quantity limits apply. |
| Cervarix (Vaccine) |
Prior authorization. For use in females 10 through 25. If the series is started prior to age 25 but the member turns 26 before the series is completed a prior authorization is required. |
| Cialis (Erectile Dysfunction) |
Prior authorization. Member must have a diagnosis of erectile dysfunction unrelated to either psychological disorders or medication side effect. Quantity Limits apply. |
| Cimzia (Crohn's) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Copaxone (Multiple Sclerosis) |
Prior authorization. For the treatment of patients with relapsing forms of multiple sclerosis. |
| Cymbalta (Antidepressant) |
Step Therapy. Member must try generic SSRI/SNRI first. |
| Daytrana (Attention Deficit/Hyperactivity Disorder) |
Prior authorization. Physician must provide documentation of medical necessity, e.g., inability to swallow oral medications. |
| Dexilant (Gastrointestinal) |
Step therapy. Member must first try/fail 2 generic Proton Pump Inhibitors. |
| Differin (Acne) |
Prior authorization. If over the age of 35, approval will not be given for treatment of cosmetic conditions; e.g., sunspots or wrinkles. |
| Dysport (Cervical Dystonia) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Edluar (Sleep Aid) |
Step therapy. Member must try zolpidem (generic Ambien) or zaleplon (generic Sonata) first. |
| Embeda |
Prior Authorization Required |
| Enbrel (Arthritis/Psoriasis) |
Prior authorization. Treatment with Enbrel is indicated for the following when conventional DMARD therapy has been unsuccessful: Ankylosing spondylitis, moderate to severely active polyarticular juvenile idiopathic arthritis, adult chronic moderate to severe plaque psoriasis, active psoriatic arthritis and moderatel to severely active rheumatoid arthritis. |
| Epiduo (Acne) |
Prior authorization. If over the age of 35, approval will not be given for treatment of cosmetic conditions; e.g., sunspots or wrinkles. |
| Erbitux (Cancer) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Extavia (Multiple Sclerosis) |
Prior authorization. For the treatment of patients with relapsing forms of multiple sclerosis. |
| Fenoglide (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Fentora (Pain) |
Prior Authorization. For the treatment of cancer-related pain. |
| Frova (Migraine) |
Step Therapy. Member must first try sumatriptan or Imitrex. |
| Gardasil (Vaccine) |
Prior authorization. For use in females & males age 9 through 26. If the series is started prior to age 26 but the member turns 27 before the series is completed a prior authorization is required. |
| Genotropin (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: pediatric growth hormone deficiency, growth failure in children small for gestational age (SGA) or with intrauterine growth retardation, Turner Syndrome, Prader-Willi Syndrome, adult growth hormone deficiency syndrome and idiopathic short stature (non-growth hormone deficient). |
| Herceptin (Cancer) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Humatrope (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: pediatric growth hormone deficiency, growth failure in children small for gestational age (SGA) or with intrauterine growth retardation, Turner Syndrome, adult growth hormone deficiency syndrome, idiopathic short stature (non-growth hormone deficient), short stature due to homeobox (SHOX) gene deficiency. |
| Humira (Arthritis/Psoriasis) |
Prior authorization. Treatment with Humira is indicated for the following when conventional DMARD therapy has been unsuccessful: Ankylosing spondylitis, juvenile idiopathic arthritis, adult chronic severe plaque psoriasis, active psoriatic arthritis, moderate to severely active adult rheumatoid arthritis and moderate to severely active adult Crohn's disease. |
| IV Immunoglobulin |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Increlex (Growth Factor) |
Prior authorization required. |
| Infergen (Hepatitis C) |
Prior authorization. Indicated for patients with chronic Hepatitis C. The prescribing physician is a gastroenterologist, hepatologist or infectious disease specialist and patients must be considered naive to treatment (previously untreated) with pegylated interferon. |
| Intuniv (ADHD) |
Prior authorization. Member must try two stimulants and immediate-release guanfacine first. |
| Itraconazole (Antifungal) |
Prior authorization. Approval will not be given for treatment of cosmetic conditions, e.g., uncomplicated nail fungus. |
| Kineret (Arthritis) |
Prior authorization required. |
| Kuvan (Phenylketonuria) |
Prior authorization required. |
| Lamisil Granules (Antifungal) |
Prior authorization. Approval will not be given for treatment of cosmetic conditions, e.g., uncomplicated nail fungus. |
| Levitra (Erectile Dysfunction) |
Prior authorization. Member must have a diagnosis of erectile dysfunction unrelated to either psychological disorders or medication side effect. Quantity Limits apply. |
| Lexapro (Antidepressant) |
Step Therapy. Member must try generic SSRI/SNRI first. |
| Lipofen (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Lofibra Caps (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Lofibra Tab (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Lopid (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Lunesta (Sleep Aid) |
Step therapy. Member must try zolpidem (generic Ambien) or zaleplon (generic Sonata) first. |
| Luvox CR (Antidepressant) |
Step Therapy. Member must try generic SSRI/SNRI first. |
| Maxalt (Migraine) |
Step Therapy. Member must first try sumatriptan or Imitrex. |
| Mirapex ER (Parkinson's Disease) |
Prior authorization. Member must have a diagnosis of Parkinson's Disease. |
| Myobloc (Cervical Dystonia) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Nexium (Gastrointestinal) |
Step therapy. Member must first try/fail 2 generic Proton Pump Inhibitors. |
| Norditropin (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: pediatric growth hormone deficiency, growth failure in children small for gestational age (SGA) or with intrauterine growth retardation, Turner Syndrome, adult growth hormone deficiency syndrome and Noonan Syndrome. |
| Noxafil (Antifungal) |
Prior authorization. Approval required to ensure drug is being used for an approved indication and duration of therapy. |
| Nutropin (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: pediatric growth hormone deficiency, growth failure secondary to chronic renal failure/insufficiency in children who have not received a renal transplant, Turner Syndrome, adult growth hormone deficiency syndrome and idiopathic short stature (non-growth hormone deficient). |
| Nutropin AQ (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: pediatric growth hormone deficiency, growth failure secondary to chronic renal failure/insufficiency in children who have not received a renal transplant, Turner Syndrome, adult growth hormone deficiency syndrome and idiopathic short stature (non-growth hormone deficient). |
| Nuvigil (Narcolepsy) |
Prior authorization. Physician must provide documentation of medical necessity, e.g. excessive sleepiness related to narcolepsy, sleep apnea with CPAP, Multiple Sclerosis or Parkinson's Disease. |
| Oleptro (Depression) |
Prior authorization. For the treatment of Major Depressive Disorder after failure of immediate-release trazodone and inability to take medications multiple times per day. |
| Omnitrope (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: pediatric growth hormone deficiency and adult growth hormone deficiency syndrome. |
| Onsolis (Pain) |
Prior Authorization. For the treatment of cancer-related pain. |
| Oral Contraceptives |
Requires prior authorization if your plan does not cover this benefit |
| Orencia (Rheumatoid Arthritis) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Peg-Intron (Hepatitis C) |
Prior authorization. Indicated for patients with chronic Hepatitis C. The prescribing physician is a gastroenterologist, hepatologist or infectious disease specialist and patients must be considered naive to treatment (previously untreated) with pegylated interferon. |
| Pegasys (Hepatitis C) |
Prior authorization. Indicated for patients with chronic Hepatitis C. The prescribing physician is a gastroenterologist, hepatologist or infectious disease specialist and patients must be considered naive to treatment (previously untreated) with pegylated interferon. |
| Pegasys Kit (Hepatitis C) |
Prior authorization. Indicated for patients with chronic Hepatitis C. The prescribing physician is a gastroenterologist, hepatologist or infectious disease specialist and patients must be considered naive to treatment (previously untreated) with pegylated interferon. |
| Penlac (Antifungal) |
Prior authorization. Physician must provide documentation that oral alternatives are not appropriate. |
| Pexeva (Antidepressant) |
Step Therapy. Member must try generic SSRI/SNRI first. |
| Prevacid Solutabs (Gastrointestinal) |
Prior authorization required. Member must be unable to swallow other dosage forms. |
| Pristiq (Antidepressant) |
Step therapy required |
| Promacta (ITP) |
Prior Authorization. For the treatment of idiopathic thrombocytopenic purpura (ITP) who have failed treatment with steroids, immunoglobulins, or removal of the spleen. |
| Provigil (Narcolepsy) |
Prior authorization. Physician must provide documentation of medical necessity, e.g. excessive sleepiness related to narcolepsy, sleep apnea with CPAP, Multiple Sclerosis or Parkinson's Disease. |
| Rebif Syringe 22MCG/0.5ML (Multiple Sclerosis) |
Prior authorization. For the treatment of patients with relapsing forms of multiple sclerosis. |
| Rebif Syringe 44MCG/0.5ML (Multiple Sclerosis) |
Prior authorization. For the treatment of patients with relapsing forms of multiple sclerosis. |
| Rebif Titration Pack (Multiple Sclerosis) |
Prior authorization. For the treatment of patients with relapsing forms of multiple sclerosis. |
| Relpax (Migraine) |
Step Therapy. Member must first try sumatriptan or Imitrex. |
| Remicade (Arthritis/Psoriasis) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Requip XL (Parkinson's Disease) |
Prior authorization. Member must have a diagnosis of Parkinson's Disease. |
| Retin-A (Acne) |
Prior authorization. If over the age of 35, approval will not be given for treatment of cosmetic conditions; e.g., sunspots or wrinkles. |
| Revatio (Pulmonary Hypertension) |
Prior authorization. For the treatment of Pulmonary Arterial Hypertension. |
| Rituxan (Cancer) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Rozerem (Sleep Aid) |
Step therapy. Member must try zolpidem (generic Ambien) or zaleplon (generic Sonata) first. |
| Saizen (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: pediatric growth hormone deficiency and adult growth hormone deficiency syndrome. |
| Serostim (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: HIV-associated wasting or cachexia. |
| Simponi (Arthritis) |
Prior authorization. Treatment with Simponi is indicated for the following when conventional DMARD therapy has been unsuccessful: Moderately to severely active rheumatoid arthritis, active psoriatic arthritis, active ankylosing spondylitis. |
| Singulair (Asthma) |
Step therapy. For treatment of allergic rhinitis, members greater than 18 years of age must try a nasal steroid and a non-sedating antihistamine. |
| Sporanox Capsules (Antifungal) |
Prior authorization. Approval will not be given for treatment of cosmetic conditions, e.g., uncomplicated nail fungus. |
| Sporanox Solution (Antifungal) |
Prior authorization. Approval will not be given for treatment of cosmetic conditions, e.g., uncomplicated nail fungus. |
| Stelara (Psoriasis) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Sumavel Dosepro (Migraine) |
Prior authorization required. Must provide medical justification that sumatriptan oral, nasal, and injectable forms cannot be used. |
| Synagis (Infection) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Tasigna (Leukemia) |
Prior authorization required |
| Tev-Tropin (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: pediatric growth hormone deficiency. |
| Tretin-X (Acne) |
Prior authorization. If over the age of 35, approval will not be given for treatment of cosmetic conditions; e.g., sunspots or wrinkles. |
| Treximet (Migraine) |
Prior authorization required |
| Tricor (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Triglide (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Trilipix (Cholesterol) |
Step Therapy. Member must first try generic fenofibrate, micronized fenofibrate, or gemfibrozil first. |
| Tykerb (Cancer) |
Prior authorization required |
| Tysabri (Multiple Sclerosis) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Tyvaso (Pulmonary Hypertension) |
Prior authorization. For the treatment of Pulmonary Arterial Hypertension. |
| Uloric (Gout) |
Prior authorization. Member must first fail or be unable to tolerate treatment with allopurinol (generic Zyloprim). For the treatment of Gout. |
| Vectibix (Cancer) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Ventavis (Pulmonary Hypertension) |
Prior authorization. For the treatment of Pulmonary Arterial Hypertension. |
| Viagra (Erectile Dysfunction) |
Prior authorization. Member must have a diagnosis of erectile dysfunction unrelated to either psychological disorders or medication side effect. Quantity Limits apply. |
| Victoza (Diabetes) |
For the treatment of Type 2 Diabetes when other drugs to treat diabetes have been tried and/or have failed. |
| Wellbutrin SR (Antidepressant) |
If using for smoking cessation, refer to your Benefits Certificate, Coverage Manual or Policy. |
| Wellbutrin XL (Antidepressant) |
If using for smoking cessation, refer to your Benefits Certificate, Coverage Manual or Policy. |
| Xenazine (Huntington's Disease) |
Prior authorization. For the treatment of Huntington's Disease. |
| Xolair (Asthma) |
Prior approval recommended. Refer to Wellmark Medical Policy. |
| Xyzal (Antihistamine) |
Step therapy. Member must have seasonal allergies AND try Zyrtec, Zyrtec OTC or Zyrtec-D AND also try fexofenadine (generic Allegra). |
| Ziana (Acne) |
Prior authorization. If over the age of 35, approval will not be given for treatment of cosmetic conditions; e.g., sunspots or wrinkles. |
| Zomig (Migraine) |
Step Therapy. Member must first try sumatriptan or Imitrex. |
| Zorbtive (Growth Hormone) |
Prior authorization. Treatment with growth hormone is indicated for the following: short bowel syndrome. |
| Zyclara (Actinic Keratosis) |
Prior authorization. Member must have tried alternative therapies prior to approval. |
| Zyflo (Asthma) |
Step therapy. For treatment of allergic rhinitis, members greater than 18 years of age must try a nasal steroid and a non-sedating antihistamine. |
| Zyflo CR (Asthma) |
Step therapy. For treatment of allergic rhinitis, members greater than 18 years of age must try a nasal steroid and a non-sedating antihistamine. |
