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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 855-816-6389 for more information.
Drug Class
Drugs Requiring Prior Authorization
Acne Medications ADAPALENE RETIN-A MICRO
ATRALIN tretinoin
AVITA tretinoin microspheres
DIFFERIN TRETIN-X
RETIN-A
Allergy Therapy Agents grass pollen-orchard/sweet
vernal/rye/kentucky/timothy, std.
ORALAIR RAGWITEK
grass pollen-timothy, std weed pollen-short ragweed
GRASTEK
Alzheimer's Agents memantine hcl/donepezil hcl NAMZARIC
Angioedema treatment ecallantide icatibant acetate
FIRAZYR KALBITOR
Anti-Cancer Agents 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
Drug Class
Drugs Requiring Prior Authorization
Anti-Cancer Agents— 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 Agents deferasirox FERRIPROX
deferiprone JADENU
EXJADE
Anti-Alcoholic Agents naltrexone microspheres VIVITROL
Anti-Arthritic (Anti-Folate) methotrexate/pf RASUVO
OTREXUP
Anti-Arthritis Agents 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
Drug Class
Drugs Requiring Prior Authorization
Anticoagulant edoxaban tosylate SAVAYSA
Anti-Constipation Agents 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) Agents KYNAMRO mipomersen sodium
Anti-Hypertension Agents 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
Immunomodulator (for dry eye)
cyclosporine RESTASIS
Antileprotic Agents thalidomide THALOMID
Anti-Narcolepsy Agents armodafinil NUVIGIL
MODAFINIL PROVIGIL
Anti-Nausea/Vertigo Agents AKYNZEO netupitant/palonosetron hcl
Antiparkinsonism Drug, APOKYN carbidopa/levodopa
Other apomorphine hcl DUOPA
Antipsychotic ADASUVE loxapine
Antiviral Agent palivizumab SYNAGIS
Antiviral Agent (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 Agent omalizumab XOLAIR
Bile Acid Disorder Agent CHOLBAM cholic acid
Blood Calcium Reducing Agent
cinacalcet hcl SENSIPAR
Cancer lenalidomide REVLIMID
Drug Class
Drugs Requiring Prior Authorization
COPD Agent DALIRESP roflumilast
Cystic Fibrosis Agent dornase alfa KALYDECO
ivacaftor PULMOZYME
Diabetic Ulcer / Wound Agent
becaplermin REGRANEX
Diuretic Agent SAMSCA tolvaptan
Enzyme—Joint Therapy COLLAGENASE CLOSTRIDIUM HISTOLYTICUM XIAFLEX
Enzyme Agents (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 Agent CERDELGA miglustat
eliglustat tartrate ZAVESCA
Gout Agent 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
Agent
Heart Failure Agent 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
Drug Class
Drugs Requiring Prior Authorization
Lipodystrophy metreleptin MYALEPT
(Low Body Fat) Agent
Multiple Sclerosis / Crohn's natalizumab TYSABRI
Multiple Sclerosis Agent 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 Agent sodium oxybate XYREM
Narcotic Withdrawal Agent BUNAVAIL BUPRENORPHINE-NALOXONE
BUPRENORPHINE HCL SUBOXONE
buprenorphine hcl/naloxone hcl ZUBSOLV
Neuromuscular Blocking abobotulinumtoxina MYOBLOC
Agents BOTOX onabotulinumtoxina
DYSPORT rimabotulinumtoxinb
incobotulinumtoxina XEOMIN
Non-24-Hour Sleep-Wake HETLIOZ tasimelteon
Disorder Agent
NSAID diclofenac epolamine DICLOFENAC SODIUM
FLECTOR SOLARAZE
Orthostatic Hypotension droxidopa NORTHERA
(NOH) Agent
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
Agent
Psoriasis Agent apremilast secukinumab
COSENTYX STELARA
Drug Class
Drugs Requiring Prior Authorization
Pulmonary Fibrosis Agent ESBRIET OFEV
nintedanib esylate pirfenidone
Pulmonary Hypertension ADCIRCA REMODULIN
Agent 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
Agent 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 Agent abatacept tocilizumab
ACTEMRA tofacitinib citrate
ORENCIA XELJANZ
Rosacea Agents brimonidine tartrate MIRVASO
ivermectin SOOLANTRA
Short Bowel Syndrome GATTEX teduglutide
Smoking Deterrent CHANTIX varenicline tartrate
Stem Cell Transplantation MOZOBIL plerixafor
Agent
Topical ELIDEL PROTOPIC
Immunosuppressive pimecrolimus TACROLIMUS
Agents
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
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