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><strong>Program</strong> <strong>Information</strong><strong>Prior</strong> <strong>Authorization</strong>Certain drugs require prior authorization to help promote safe, quality and affordablepharmacy care. Your doctor will need to submit a prior authorization request to <strong>Prime</strong><strong>Therapeutics</strong>, which must be approved before you can continue to receive coverage forthese drugs.The <strong>Prior</strong> <strong>Authorization</strong> form that your physician will need to complete to request anapproval can be found on the My<strong>Prime</strong>Tools website (located on the same page where thisform is found).<strong>Prior</strong> <strong>Authorization</strong>program nameDrugs included in programASTHMAXolairXolairATTENTION DEFICIT-HYPERACTIVITY DISORDER (ADHD)ADHD(with quantity limit)<strong>Prior</strong> <strong>Authorization</strong> applies to Brand products only:Adderall, Adderall XR, Concerta, Daytrana, Dexedrine, Desoxyn,Dextroamphetamine, Focalin, Focalin XR, Intuniv, Kapvay, Metadate CD,Metadate ER, Methylin, Procentra, Quillivant XR, Ritalin, Ritalin LA, Ritalin SR,Strattera, VyvanseAUTOIMMUNE DISORDERSArcalyst, IlarisArcalyst, IlarisBLOOD MODIFYING DRUGSAranesp, Epogen, ProcritErythropoietinsPreferred Product: Aranesp, ProcritCANCER / ONCOLOGYAfinitor, Bosulif, Caprelsa, Cometriq, Erivedge, Gleevec, Hexalen, Hycamtin,Iclusig, Inlyta, Jakafi, Lysodren, Matulane, Nexavar, Oforta, Pomalyst, Revlimid,Self Administered Oncology Sprycel, Stivarga, Sutent, Sylatron, Tarceva, Targretin, Tasigna, Temodar,Thalomid, Tretinoin (oral), Tykerb, Votrient, Xalkori, Xeloda, Xtandi, Zelboraf,Zolinza, ZytigaDERMATOLOGYRetinoids (Topical)Applies to ages 40 and overDIABETESKorlymGROWTH HORMONEAtralin, Avita, Differin, Epiduo, Fabior, Retin-A, Retin-A Micro, Tazorac,Tretin-X, Veltin, ZianaKorlymGenotropin, Humatrope, Norditropin Flexpro, Norditropin NordiFlex, Nutropin,Nutropin AQ, Nutropin AQ Nuspin, Omnitrope, Saizen, Saizen Click.Easy,Growth HormoneSerostim, Tev-Tropin, ZorbtivePreferred Products: Norditropin, NutropinHIVEgriftaEgriftaHUNTINGTON’S CHOREAXenazineXenazineHYPERTENSION (HIGH BLOOD PRESSURE)Letairis and TracleerLetairis, TracleerAdcirca, RevatioAdcirca, RevatioMETABOLIC DISORDERSKuvanKuvanMULTIPLE SCLEROSISAmpyraAmpyra<strong>Prime</strong> <strong>Therapeutics</strong> LLC (<strong>Prime</strong>), the independent pharmacy benefit management company selected by your employer, is dedicated toproviding innovative, clinically based, cost-effective pharmacy solutions.5484-D Page 1 of 2
<strong>Prior</strong> <strong>Authorization</strong>program nameDrugs included in programSLEEP DISORDERSNuvigil ProvigilNuvigil, ProvigilWOMEN’S HEALTH (OSTEOPOROSIS)ForteoForteoMISCELLANEOUSImmune ThrombocytopenicNplate, PromactaPurpura (ITP)Brand names are the property of their respective owners.ER: extended-releaseSR: sustained-releaseUnless otherwise noted <strong>Prior</strong> <strong>Authorization</strong> <strong>Program</strong>s will apply to both brand and generic equivalents<strong>Program</strong>s subject to change without notice<strong>Prime</strong> <strong>Therapeutics</strong> LLC (<strong>Prime</strong>), the independent pharmacy benefit management company selected by your employer, is dedicated toproviding innovative, clinically based, cost-effective pharmacy solutions.5484-D Page 2 of 2
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