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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive
drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that
require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services
department at 860-674-2851 or toll-free at 800-249-1367 by the prescribing physician’s office. POS members
receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior
Authorization, please use a Prior Authorization form which can be obtained from ConnectiCare.com or by
calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual
at a participating pharmacy or administered by a provider (where appropriate).
Note: Self-administered medications (i.e. interferons), even those not on this list, may not be dispensed for self
administration and billed through the medical benefit by a provider. They must be dispensed through a
participating pharmacy.
(*) prior authorization is not required within the first 90 days of membership with ConnectiCare.
(M) physician-administered drug, usually billed under the medical benefit.
The information in this document does not apply to members with ConnectiCare VIP Medicare Plans,
ConnectiCare Exchange Plans and most of ConnectiCare® SOLO Plans.
To find a drug, click on a letter and browse the table alphabetically.
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MEDICATION
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COMMENTS
*Abilify/Maintena
Absorica
Abstral
Aciphex/generic rabeprazole
(Use OTC PPI first)
Actemra
Acthar Gel
Actiq/generic fentanyl lozenge
*Actonel
(Use alendronate first)
*ActoplusMet XR
(Use metformin first)
M
Adcetris
Adcirca
*Adempas
*Adoxa
(Use generics first)
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Afinitor
Afrezza
M
Aldurazyme
M
Alimta
AlleRx
(Use Allegra, Zyrtec, and Claritin OTC first—covered)
Alsuma
*Altoprev
(Use simva-, prava-, lovastatin first)
*Ambien CR/generic zolpidem ER
(Use Ambien)
Amevive
Ampyra
Amrix/generic cyclobenzaprine ER
(Use older generics first)
*Amturnide
(Use generic ACE or ARB first)
Androderm
Androgel
Antara
Anzemet
(Use ondansetron first)
Apidra
Aplenzin
(Use generic bupropion hcl)
Apokyn
M
Aralast
M
Arcalyst
Aricept 23
Arnuity Ellipta
Arthrotec
M
Arzerra
Ascensia Test Strips
(Use Accuchek or Freestyle)
*Astepro Nasal Spray/generic azelastine 0.15%
(Use Astelin)
*Atelvia
(Use alendronate)
Aubagio
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
*Avandamet
(Use metformin first)
*Avandaryl
(Use metformin first)
*Avandia
(Use metformin first)
M
(PA not required for use in the eye)
Avastin
Aveed injection
Avidoxy
(Use generic first)
Avodart
Avonex
*Axert
(Use generic triptan first)
Axiron
*Azor
(Use generic ACE or ARB first)
*Beconase AQ
(Use generic Flonase first)
Belsomra
*Benicar/Benicar HCT
M
(Use generic ACE or ARB first)
Benlysta
Berinert
Betaseron
M
Bexxar
*Binosto
M
Blood Clotting Factors (All)
Boniva Injection
Bosulif
Botox
Bravelle
Breo Ellipta
*Brintellix
*Brisdelle
Brovana
Buphenyl
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
*Bydureon
*Byetta
(Use metformin first)
Cambia
Campral/generic acamprosate
Caprelsa
Cayston
*Celebrex
M
Cerdelga
M
Cerezyme
Cesamet
Cetrotide
Cimzia
Cinryze
Clarinex/Clarinex D/generic desloratadine
(Use Allegra, Zyrtec, and Claritin OTC first—covered)
Clobex Lotion
(Use generic clobetasol first)
Clolar
Clomid/generic clomiphene
CNL Nail Kit
Coartem
Cometriq
Compounded Medications
Contraceptives (if excluded by group)
Copaxone
*Coreg CR
(Use carvedilol first)
*Crestor
Crinone
Cuvposa
Cyramza
M
Dacogen
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
*Daliresp
*Desvenlafaxne Fumarate
*Detrol/Detrol LA/generic tolterodine
(Use oxybutynin IR/XL first)
Dexilant
(Use OTC Prevacid or Prilosec 1st)
*Differin 0.3%
(Use 0.1% first)
Dificid
*Doryx
(Use generics first)
Dovonex
*Duetact
(Use metformin first)
Duexis
Dymista
Dysport
Ecoza
*Edarbi
*Edarbyclor
*Edluar
(Use zolpidem generic tablets)
Egrifta
M
Elaprase
Elelyso
M
Eloxatin
(Use oxybutynin IR/XL first)
*Enablex
Enbrel
Endometrin
Entyvio
Epanova
Epinephrine Auto-Injector
M
Erbitux
Erivedge
Esomeprazole Strontium
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
M
COMMENTS
Euflexxa
Evzio
*Exalgo
(#14 allowed, use formulary agent first)
*Exelon patch
*Exforge/Exforge HCT
(Use generic ACE or ARB first)
Exjade
Extavia
M
Fabrazyme
*Fanapt
*Farxiga
Fenoglide
Fentora
*Fetzima
Fexmid
Fibrocor
Firazyr
Flector Patch
M
Flolan/epoprostenol
Fluoxetine 60mg
Follistim AQ
Folotyn
Fortamet
(Use generic metformin first)
Fortesta
Forfivo XL
Fosamax Solution
(Use alendronate)
*Frova
(Use generic triptan first)
Fuzeon
Ganirelix
Gastrocrom
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Gattex
Gazyva
*Gelnique
M
Gel-One
Genotropin
Gilenya
Gilotrif
Glassia
Gleevec
Glumetza
(Use generic metformin first)
Gonal-F
Gralise
Grastek
Growth Hormones (All)
M
Halaven
HCG (chorionic gonadotropin)
M
Herceptin
Hetlioz
M
Hizentra
Horizant
Humatrope
Humira
M
Hyalgan
Hycamtin Capsules
Iclusig
Ilaris
Imbruvica
Impavido
Implanon
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Increlex
Inderal XL
Infertility Medications (All)
Injectable Drugs – All (excluding insulin)
Inlyta
Intermezzo
Intron-A
*Intuniv
*Invega/Sustenna
*Invokana
(Use metformin first)
*Invokamet
M
Istodax
M
IV Immune Globulin (IVIG)
M
Ixempra
Jakafi
*Jardiance
Μ
Jevtana
Jublia
Juxtapid
M
Kadcyla
M
Kalbitor
Kalydeco
Karbinal ER
Kazano
(Use metformin and Sitagliptin or Linagliptin first)
Kerydin
M
Keytruda
*Khedezla
Kineret
Klonopin Wafers/generic clonazepam wafers
(Use clonazepam tablets)
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
*Kombiglyze XR
(Use metformin and Sitagliptin or Linagliptin first)
Korlym
M
Krystexxa
Kuvan
Kynamro
M
Kyprolis
Kytril/generic granisetron
(Use generic Zofran first)
Lamictal ODT
*Lamictal XR/generic lamotrigine ER
*Latuda
Lazanda
*Lescol/XL
(Use generic statin first)
Letairis
Liptruzet
Livalo
Lofibra
Lotronex
Lovaza/generic Omega 3 acid ethyl esters
Lumigan
Lumizyme
*Lunesta/generic eszopiclone
(Use generic Ambien)
Luveris
*Luvox CR
(Use generics first)
*Luxiq
(Use generic betamethasone first)
Luzu
*Lyrica
M
Macugen
Makena
Marinol/generic dronabinol
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Marqibo
Mekinist
Menopur
Mepron/generic atovaquone
Metozolv
(Use generic first)
M
(PA on pharmacy side only)
Mirena
Monovisc
M
Mozobil
M
Myobloc
M
Myozyme
*Myrbetriq
M
Naglazyme
Namenda
(PA < 50 years old only)
Naprelan
*Nasarel
(Use fluticasone or Nasonex)
Natesto
Nesina
(Use metformin and Sitagliptin or Linagliptin first)
Nexavar
Nexium
(Use OTC PPI’s first)
Nexplanon
PA not required under medical benefit
Nimotop
Norditropin
Novarel
Novolin/Novolog
M
Novoseven
M
Nplate
Nuedexta
M
Nulojix
Nutropin/AQ
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Nuvigil
Oforta
Oleptro
Olux
(Use generic clobetasol first)
Olux-E
Olysio
*Omnaris
(Use fluticasone or Nasonex)
Omnitrope
Omtryg
One Touch Test Strips
(Use Accuchek or Freestyle)
Onglyza
(Use metformin and Sitagliptin or Linagliptin first)
Onsolis
Opana ER (crush resistant formulation)
*Opsumit
*Oracea
Oralair
Oravig
M
Orencia/Orencia SQ
Orfadin
M
Orthovisc
Oseni
(Use metformin and Sitagliptin or Linagliptin first)
Otezla
Otrexup
Ovidrel
*Oxtellar XR
Oxycodone AG (Oxycontin Authorized Generic)
*Oxytrol
(Use generic oxybutynin IR/XL first)
Ozurdex
Patanase
(Use Astelin first)
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Pegasys
Peg-Intron
Pennsaid
M
Perjeta
*Pexeva
(Use generics first)
Plegridy
Pomalyst
Ponstel/generic mefenamic acid
(Use generic NSAIDs)
Prevacid
(Use Prevacid OTC—Tier 1)
M
Prialt
Prilosec
(Use Prilosec OTC—Tier 1)
*Pristiq
(Use venlafaxine first)
Prolastin
M
Proleukin
Prolia
Promacta
Procysbi
Protonix
M
(Use Prilosec OTC)
Provenge
Provigil/generic modafinil
*Prozac Weekly
(Use generics first)
Qudexy XR
*Qnasl
Qualaquin
Qutenza
Ragwitek
*Rapaflo
(Use Flomax first)
*Rayos
Ravicti
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Drug Prior Authorization List | Effective Oct 2014
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Rebif
Regranex
Relistor
*Relpax
M
Remicade
M
Remodulin
(Use generic triptan first)
Repronex
M
Retisert
Revatio/generic sildenafil
Revlimid
M
RiaSTAP
Ribavirin (Ribapak)
*Risperdal Consta
M
Rituxan
Ruconest
Saizen
*Sanctura
(Use oxybutynin IR/XL first)
Sancuso
(Use ondansetron first)
*Saphris
*Sarafem
(Use generics first)
Signifor
Silenor
Simponi/Simponi ARIA
M
Skyla
(PA on pharmacy side only)
Solodyn
M
Soliris
Somavert
Sorilux Foam
Sovaldi
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Sporanox/generic itraconazole
Sprix Nasal spray
Sprycel
*Stavzor
(Use generic first)
Stelara
Stivarga
*Strattera
Striant
Subsys
Sucraid
Sumavel Dosepro
M
Supartz
Supprelin LA
Sutent
Sylatron
Sylvant
*Symlin
M
Synagis
Synarel
Synribo
M
Synvisc
Tafinlar
*Tanzeum
Tarceva
Tasigna
Tecfidera
*Tekamlo
(Use generic ACE or ARB first)
*Tekturna
(Use generic ACE or ARB first)
Temodar/generic temozolomide
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Drug Prior Authorization List | Effective Oct 2014
Page 14 of 17
DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
COMMENTS
Testim/generic testosterone transdermal gel
Testosterone (All)
*Tevetan HCT
(Use generic ACE or ARB first)
TevTropin
Thalomid
Thyrogen
Tivorbex
M
Torisel
*Toviaz
(Use oxybutynin IR/XL first)
Tracleer
Travatan/Travatan Z
Travel Medication: i.e. Malarone
M
Treanda
Tretin-X
(Use tretinoin first)
Treximet
(Use sumatriptan with naproxen)
*Tribenzor
(Use generic ACE or ARB first)
Triglide
Trokendi XR
Trospium
(Use oxybutynin IR/XL first)
Tykerb
Tysabri
Tyvaso
*Uloric
(Use allopurinol first)
Ultram ER/generic tramadol ER
(Use immediate release generic)
Valchlor
*Valturna
(Use generic ACE or ARB first)
Vanos
Vantas
Vascepa
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
M
Vectibix
M
Velcade
COMMENTS
Velphoro
Venlafaxine Extended Release Tabs
M
(Use generics first)
Ventavis
Verdeso
(Use generic desonide first)
*Versacloz
*Vesicare
(Use oxybutynin IR/XL first)
*Victoza
(Use metformin first)
Victrelis
M
Vidaza
*Viibryd
Vimizim
Vimovo
M
Vivitrol
Vogelxo
Voltaren Gel
Votrient
M
Vpriv
Vusion
*Vytorin
(Use simva-, prava-, lovastatin first)
Weight Loss Medication (if covered by your plan)
*Welchol
Xalkori
Xartemis XR
Xeljanz
Xeloda/generic capecitabine
Xenazine
M
Xeomin
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DRUG PRIOR AUTHORIZATION LIST
This list does not apply to members of ConnectiCare Exchange Plans and
most ConnectiCare® SOLO Plans using the Freedom Drug List.
MEDICATION
M
Xgeva
M
Xiaflex
COMMENTS
Ximino
Xofigo
Xolair
Xtandi
M
Xyntha
Xyrem
M
Yervoy
M
Zaltrap
Zavesca
Zecuity
Zegerid
(PA for > 15 y/o) (Use OTC or OTC Prevacid/Prilosec)
Zelboraf
M
Zemaira
*Zetonna
Zipsor
(Use diclofenac tablets)
Zohydro ER
Zolinza
Zolpimist
(Use generic zolpidem tablets)
Zontivity
Zortress
Zorvolex
Zuplenz
Zyban
(Use bupropion)
Zydelig
Zyflo CR
(Use Singulair first)
Zykadia
Zytiga
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Drug Prior Authorization List | Effective Oct 2014
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