Prior authorization helps ensure that covered medications provide the best safety and value. It is needed when a medication has only been proven to benefit a limited number of people or if unusually large doses are requested for coverage. These medications require prior authorization Possible alternatives because alternatives may offer a better value Cholesterol atorvastatin, Crestor® simvastin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®) simvastin (Zocor®), pravastatin (Pravachol®), lovastatin Depression bupropion SR (Wellbutrin SR®), bupropion XL 300mg (Wellbutrin
XL®), fluoxetine (Prozac®), fluvoxamine maleate, mirtazapine
(Remeron®), paroxetine (Paxil®), sertraline (Zoloft®) Diabetes
ACTOplus Met™, Actos®, Avandamet®, Avandaryl™,
metformin
(Glucophage®), glimepiride (Amaryl®), glipizide
(Glucotrol®), glyburide (Diabeta®), insulin
Kombiglyze™ XR, Onglyza™, Tradjenta™, Victoza® High Blood Pressure benazepril/HCT (Lotensin/HCT®), captopril/HCT (Capoten/
Benicar®, Benicar HCT®, Micardis®, Micardis HCT®
Captozide®), enalapril/HCT (Vasotec/Vaseretic®), fosinopril/ HCT (Monopril/HCT®), lisinopril/HCT (Zestril/Zestoretic®,
Prinivil/Prinzide®), losartan/HCT (Cozaar/Hyzaar®), moexipril/ HCT (Univasc/Uniretic®), quinapril/HCT (Accupril/Accuretic®), trandolapril (Mavik®)
Amturnide™, Atacand®, Atacand-HCT®, Avalide®,
benazepril/HCT (Lotensin/HCT®), captopril/HCT(Capoten/
Avapro®, Azor®, Diovan®, Diovan HCT®, Edarbi™,
Captozide®), enalapril/HCT (Vasotec/Vaseretic®), fosinopril/
Exforge®, Exforge HCT®, Tekamlo™, Tekturna®, Tekturna HCT (Monopril/HCT®), lisinopril/HCT (Zestril/Zestoretic®, Prinivil/
HCT®, Teveten®, Teveten HCT®, Tribenzor™, Twynsta®,
Prinzide®), losartan/HCT (Cozaar/Hyzaar®), moexipril/HCT (Univasc/
Uniretic®), quinapril/HCT (Accupril/Accuretic®), trandolapril
(Mavik®), Benicar®, Benicar HCT®, Micardis®, Micardis HCT®
Mental Health clozapine
Abilify®, Fanapt®, Geodon®, Invega®, Latuda®, Saphris®,
(Clozaril®), olanzapine (Zyprexa®), risperidone ziprasidone Migraines sumatriptan (Imitrex®)
Alsuma™, Amerge®, Axert®, Frova®, naratriptan HCL,
Sumavel™ DosePro™, Treximet™, Zomig®, Zomig-ZMT®
sumatriptan (Imitrex®), Maxalt®, Maxalt-MLT®, Relpax® Multiple Sclerosis Nasal Steroids flunisolide
Beconase AQ®, Nasonex®, Omnaris®, Qnasl™, Rhinocort
(Nasalide®), fluticasone (Flonase®), triamcinolone acetonide Pain and Inflammation
Generic non-steroidal anti-inflammatory medications (NSAIDs)
such as: diclofenac (Voltaren®), etodolac (Lodine®), flurbiprofen
(Ansaid®), ibuprofen (Motrin®), indomethacin (Indocin®), ketoprofen (Orudis®), nabumetone (Relafen®), naproxen
(Naprosyn®), oxaprozin (Daypro®), piroxicam (Feldene®), salsalate
(Disalcid®), sulindac (Clinoril®), tolmetin (Tolectin®) Stomach Acid lansoprazole, pantoprazole, Dexilant™, Kapidex™ omeprazole (Prilosec®)
Aciphex®, Nexium®, Prevacid®, Protonix®, Vimovo™
omeprazole (Prilosec®), Dexilant™, Kapidex™
Effective 04/12NOTE: Our medication Prior Authorization List is subject to change. If the requested medication is authorized, there maybe limits to the amount of medication that is eligible for coverage. Please call our Customer Service Department if you have any questions.
The Bottom Line – Safety is our top priority and our prior authorization program helps you and your doctors choose quality medications that provide the most value. Some alternatives might also help you save money. These medications require prior authorization Maximum quantity per month if prescribed above the maximum quantity unless otherwise specified
Imitrex® (sumatriptan succinate) injection
10 discs (2 treatment courses) per 6 months
40 capsules (2 treatment courses) per 6 months
20 capsules (2 treatment courses) per 6 months
These medications require prior authorization to determine if they can be covered for your medical condition
NOTE: In addition to the above medications, there are limits to the amount of medication eligible for coverage for all prescriptions. These
limits are based on your prescription benefit along with information from the FDA and scientific literature about maximum, safe, effective
Journal of Biotechnology 140 (2009) 250–253 Thermomyces lanuginosus lipase-catalyzed regioselective acylation ofnucleosides: Enzyme substrate recognitiona Laboratory of Applied Biocatalysis, South China University of Technology, Guangzhou 510640, China b State Key Laboratory of Catalysis, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian 116023, China Substrate
Centre for Institutional Performance Democratizing Luxury and the Contentious ‘Invention of the Technological Chicken’ in Britain Andrew Godley University of Reading, UK December 2007 CIP Working Paper No. 2007-054 [email protected] www.reading.ac.uk/cip Democratizing Luxury and the Contentious ‘Invention of the Technological Chicken’ in Britain 1 In 1950 p
Prior authorization helps ensure that covered medications provide the best safety and value. It 
The Bottom Line – Safety is our top priority and our prior authorization program helps you and your doctors