Prior Authorization Program Information - Prime Therapeutics
Prior Authorization Program Information - Prime Therapeutics
Prior Authorization Program Information - Prime Therapeutics
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<strong>Prior</strong> <strong>Authorization</strong> Drugs included in program<br />
program name<br />
HYPERTENSION (HIGH BLOOD PRESSURE)<br />
Letairis and Tracleer<br />
Letairis, Tracleer<br />
METABOLIC DISORDERS<br />
Kuvan<br />
Kuvan<br />
MULTIPLE SCLEROSIS<br />
Ampyra<br />
Ampyra<br />
PAIN MANAGEMENT<br />
Fentanyl Oral / Nasal<br />
Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys<br />
RESPIRATORY<br />
Synagis<br />
Synagis<br />
SLEEP DISORDERS<br />
Nuvigil Provigil<br />
Nuvigil, Provigil<br />
THYROID / PARATHYROID<br />
Sensipar<br />
Sensipar<br />
MISCELLANEOUS<br />
Bivigam, Carimune, Flebogamma, Flebogamma 5%, 10% DIF,<br />
GamaSTAN S/D, Gammagard S/D, Gammagard S/D (IgA less than 1<br />
Immune Globulins<br />
mcg/mL), Gammagard Liquid, Gammaked Liquid, Gammaplex Liquid,<br />
Gamunex, Gamunex-C, Hizentra, Octagam, Privigen<br />
Immune Thrombocytopenic<br />
Nplate, Promacta<br />
Purpura (ITP)<br />
Brand names are the property of their respective owners.<br />
ER: extended-release<br />
SR: sustained-release<br />
Unless otherwise noted, <strong>Prior</strong> <strong>Authorization</strong> <strong>Program</strong>s will apply to both brand drugs and their generic<br />
equivalents.<br />
This program is subject to change without notice.<br />
<strong>Prime</strong> <strong>Therapeutics</strong> LLC (<strong>Prime</strong>), the independent pharmacy benefit management company selected by your employer, is dedicated to<br />
providing innovative, clinically based, cost-effective pharmacy solutions.<br />
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