Prescription Drug Authorization Forms — Employer Plans, Individual & Family Plans, and FAMIS
If you need any assistance or have questions about the drug authorization forms please contact the Sentara Health Plans Pharmacy team by calling 800-229-5522.
Pharmacy General Exception Forms
Drug Authorization Forms
Abecma (Medical)
PDF, 215 KB
PDF, 215 KB
Abrysvo (Medical)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 147 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 147 KB
Abrysvo (Pharmacy)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 122 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 122 KB
Actimmune (Medical)
PDF, 171 KB
PDF, 171 KB
ActimmuneSQ
PDF, 195 KB
PDF, 195 KB
Adakveo (Medical)
PDF, 205 KB
PDF, 205 KB
Adalimumab (Preferred) Products
Commercial/FAMIS Preferreds: (Cyltezo | Humira | Yuflyma); Small Group/Individual Product/Exchange Preferreds: (adalimumab-adbm | Simlandi)
PDF, 242 KB
Commercial/FAMIS Preferreds: (Cyltezo | Humira | Yuflyma); Small Group/Individual Product/Exchange Preferreds: (adalimumab-adbm | Simlandi)
PDF, 242 KB
Adbry
PDF, 265 KB
PDF, 265 KB
Addyi
PDF, 153 KB
PDF, 153 KB
Adzynma (Medical)
PDF, 258 KB
PDF, 258 KB
Afrezza
PDF, 159 KB
PDF, 159 KB
Agamree | Emflaza
PDF, 202 KB
PDF, 202 KB
Albuterol Inhalers (Non-Preferred)
(albuterol HFA (generic ProAir HFA) | albuterol HFA (generic Proventil HFA) | albuterol HFA (generic Ventolin HFA) | levalbuterol HFA (generic Xopenex) | ProAir Digihaler/HFA/Respiclick | Proventil HFA)
PDF, 161 KB
(albuterol HFA (generic ProAir HFA) | albuterol HFA (generic Proventil HFA) | albuterol HFA (generic Ventolin HFA) | levalbuterol HFA (generic Xopenex) | ProAir Digihaler/HFA/Respiclick | Proventil HFA)
PDF, 161 KB
Aldurazyme (Medical)
PDF, 261 KB
PDF, 261 KB
Alhemo (Medical)
PDF, 221 KB
PDF, 221 KB
Alhemo (Pharmacy)
PDF, 210 KB
PDF, 210 KB
alosetron (Lotronex) | Viberzi
PDF, 231 KB
PDF, 231 KB
Alpha Proteinase Inhibitors (Medical)
Aralast NP | Glassia | Prolastin-C | Zemaira
PDF, 209 KB
Aralast NP | Glassia | Prolastin-C | Zemaira
PDF, 209 KB
Alvaiz | Promacta
PDF, 230 KB
PDF, 230 KB
Alyftrek
PDF, 223 KB
PDF, 223 KB
Amvuttra | Onpattro (Medical)
PDF, 284 KB
PDF, 284 KB
Antidepressant Drugs
Fetzima | Trintellix | vilazodone (Viibryd)
PDF, 164 KB
Fetzima | Trintellix | vilazodone (Viibryd)
PDF, 164 KB
Antiparkinson Agents
Crexont | Inbrija | Lodosyn | Neupro | Nourianz | Ongentys | tolcapone (Tasmar) | Rytary | Xadago
PDF, 231 KB
Crexont | Inbrija | Lodosyn | Neupro | Nourianz | Ongentys | tolcapone (Tasmar) | Rytary | Xadago
PDF, 231 KB
Aphexda (Medical)
PDF, 179 KB
PDF, 179 KB
Aqneursa
PDF, 156 KB
PDF, 156 KB
Arcalyst
PDF, 321 KB
PDF, 321 KB
Arikayce
PDF, 183 KB
PDF, 183 KB
Aspirin 81 mg (ACA Copay Waiver)
PDF, 141 KB
PDF, 141 KB
Atypical Antipsychotics
(asenapine | Caplyta | Cobenfy | Fanapt | lurasidone | paliperidone | Rexulti | Vraylar)
PDF, 165 KB
(asenapine | Caplyta | Cobenfy | Fanapt | lurasidone | paliperidone | Rexulti | Vraylar)
PDF, 165 KB
Aucatzyl (Medical)
PDF, 244 KB
PDF, 244 KB
Austedo
PDF, 165 KB
PDF, 165 KB
Auvelity ER
PDF, 188 KB
PDF, 188 KB
Auvi-Q Auto-Injector
PDF, 162 KB
PDF, 162 KB
Benlysta (Medical)
PDF, 226 KB
PDF, 226 KB
Benlysta (Pharmacy)
PDF, 300 KB
PDF, 300 KB
Beqvez (Medical)
PDF, 276 KB
PDF, 276 KB
Berinert IV (Medical)
PDF, 220 KB
PDF, 220 KB
Beyfortus (Medical)
PDF, 199 KB
PDF, 199 KB
Bimzelx
PDF, 184 KB
PDF, 184 KB
Botox | Xeomin
PDF, 197 KB
PDF, 197 KB
Botox | Xeomin (Medical)
Botulinum Toxin Injections, Type A (Botox | Xeomin)
PDF, 201 KB
Botulinum Toxin Injections, Type A (Botox | Xeomin)
PDF, 201 KB
Botox Injections-Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS)) (Medical)
Botulinum Toxin Injections, Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS))
PDF, 171 KB
Botulinum Toxin Injections, Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS))
PDF, 171 KB
Botox Injection-Type A (Chronic Migraine Headache Prophylaxis) (Medical)
Botulinum Toxin Injections, Type A (Chronic Migraine Headache Prophylaxis)
PDF, 212 KB
Botulinum Toxin Injections, Type A (Chronic Migraine Headache Prophylaxis)
PDF, 212 KB
Botox Injection-Type A (Hyperhidrosis) (Medical)
Botulinum Toxin Injections, Type A (Hyperhidrosis)
PDF, 193 KB
Botulinum Toxin Injections, Type A (Hyperhidrosis)
PDF, 193 KB
Brexafemme
PDF, 178 KB
PDF, 178 KB
Breyanzi (Medical)
PDF, 219 KB
PDF, 219 KB
Brineura IV (Medical)
PDF, 212 KB
PDF, 212 KB
Briumvi (Medical)
PDF, 198 KB
PDF, 198 KB
Brixadi│Sublocade
PDF, 176 KB
PDF, 176 KB
Brixadi│Sublocade (Medical)
PDF, 168 KB
PDF, 168 KB
Bronchitol
PDF, 210 KB
PDF, 210 KB
butorphanol (Stadol) Nasal Spray
PDF, 150 KB
PDF, 150 KB
Bylvay
PDF, 230 KB
PDF, 230 KB
Cabenuva LAP (Medical)
PDF, 164 KB
PDF, 164 KB
Cabenuva LAP (Pharmacy)
PDF, 151 KB
PDF, 151 KB
Cablivi
PDF, 222 KB
PDF, 222 KB
Camzyos
PDF, 139 KB
PDF, 139 KB
carglumic acid (Carbaglu)
PDF, 199 KB
PDF, 199 KB
Carvykti (Medical)
PDF, 217 KB
PDF, 217 KB
Casgevy - β-Thalassemia (Medical)
PDF, 277 KB
PDF, 277 KB
Casgevy (Medical)
PDF, 259 KB
PDF, 259 KB
Central Nervous System (CNS) Stimulants (Age 19 and Above)
(Adhansia XR | Adzenys XR-ODT/ER | amphetamine/dextroamphetamine (Adderall) |amphetamine/dextroamphetamine ER (Adderall XR) | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR/ODT | dexmethylphenidate (Focalin) | dexmethylphenidate ER (Focalin XR) | dextroamphetamine (Zenzedi) | dextroamphetamine (ProCentra) | dextroamphetamine (Dextrostat) | dextroamphetamine ER (Dexedrine Spansule) | Dyanavel XR | Evekeo ODT | Jornay PM | methamphetamine (Desoxyn) | methylphenidate ER (Aptensio XR) | methylphenidate ER (Concerta) | methylphenidate TID Patch (Daytrana) | methylphenidate ER (Ritalin SR/Metadate ER) | methylphenidate (Ritalin/Methylin) | methylphenidate LA (Ritalin LA) | methylphenidate CD (Metadate CD) | Mydays | Quillichew ER | Quillivant XR | Vyvanse)
PDF, 188 KB
(Adhansia XR | Adzenys XR-ODT/ER | amphetamine/dextroamphetamine (Adderall) |amphetamine/dextroamphetamine ER (Adderall XR) | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR/ODT | dexmethylphenidate (Focalin) | dexmethylphenidate ER (Focalin XR) | dextroamphetamine (Zenzedi) | dextroamphetamine (ProCentra) | dextroamphetamine (Dextrostat) | dextroamphetamine ER (Dexedrine Spansule) | Dyanavel XR | Evekeo ODT | Jornay PM | methamphetamine (Desoxyn) | methylphenidate ER (Aptensio XR) | methylphenidate ER (Concerta) | methylphenidate TID Patch (Daytrana) | methylphenidate ER (Ritalin SR/Metadate ER) | methylphenidate (Ritalin/Methylin) | methylphenidate LA (Ritalin LA) | methylphenidate CD (Metadate CD) | Mydays | Quillichew ER | Quillivant XR | Vyvanse)
PDF, 188 KB
Central Nervous System (CNS) Stimulants (Non-Preferred)
(Adhansia XR | Adzenys XR-ODT | Adzenys ER Susp | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR-ODT | Dyanavel XR | Evekeo ODT | Jornay PM | methylphenidate ER (Aptensio XR) | methylphenidate TD Patch (Daytrana) | Mydayis | Quillichew ER | Quillivant XR)
PDF, 176 KB
(Adhansia XR | Adzenys XR-ODT | Adzenys ER Susp | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR-ODT | Dyanavel XR | Evekeo ODT | Jornay PM | methylphenidate ER (Aptensio XR) | methylphenidate TD Patch (Daytrana) | Mydayis | Quillichew ER | Quillivant XR)
PDF, 176 KB
Chenodal
PDF, 178 KB
PDF, 178 KB
Cholbam
PDF, 188 KB
PDF, 188 KB
Cibinqo
PDF, 193 KB
PDF, 193 KB
Cimzia Lyophilized (Medical)
PDF, 196 KB
PDF, 196 KB
cinacalcet (Sensipar)
PDF, 198 KB
PDF, 198 KB
Cinqair IV (Medical)
PDF, 169 KB
PDF, 169 KB
Compound Drugs
PDF, 139 KB
PDF, 139 KB
Continuous Glucose Monitors (CGM) & Subcutaneous Insulin Pumps (Group Specific Benefit)
(PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)
PDF, 182 KB
(PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)
PDF, 182 KB
Corlanor
PDF, 181 KB
PDF, 181 KB
Cosentyx IV (Medical)
PDF, 214 KB
PDF, 214 KB
Cosentyx SQ (Pharmacy)
PDF, 226 KB
PDF, 226 KB
Cresemba (Medical)
PDF, 258 KB
PDF, 258 KB
Cresemba (Pharmacy)
PDF, 200 KB
PDF, 200 KB
Crinone
PDF, 152 KB
PDF, 152 KB
Crysvita Injection (Medical)
PDF, 212 KB
PDF, 212 KB
Cuvrior | Syprine | trientine
PDF, 187 KB
PDF, 187 KB
Cystaran | Cystadrops
PDF, 188 KB
PDF, 188 KB
Daxxify
PDF, 160 KB
PDF, 160 KB
Daxxify (Medical)
PDF, 166 KB
PDF, 166 KB
Daybue
PDF, 214 KB
PDF, 214 KB
Dextenza (Medical)
PDF, 221 KB
PDF, 221 KB
Diacomit
PDF, 155 KB
PDF, 155 KB
dichlorphenamide (Keveyis)
PDF, 162 KB
PDF, 162 KB
Dificid
PDF, 219 KB
PDF, 219 KB
Dipetidyl Peptidase 4 (DPP4) Inhibitors
(alogliptin (Nesina ABA) | alogliptin-pioglitazone (Oseni ABA)| alogliptin-metformin (Kazano ABA)| Kazano | Nesina | Oseni | saxagliptin (Onglyza) | saxagliptin-metformin ER (Kombigliyze XR) | Zituvio)
PDF, 147 KB
(alogliptin (Nesina ABA) | alogliptin-pioglitazone (Oseni ABA)| alogliptin-metformin (Kazano ABA)| Kazano | Nesina | Oseni | saxagliptin (Onglyza) | saxagliptin-metformin ER (Kombigliyze XR) | Zituvio)
PDF, 147 KB
Dojolvi
PDF, 249 KB
PDF, 249 KB
Doptelet
PDF, 207 KB
PDF, 207 KB
doxylamine-pyridoxine (Diclegis)
PDF, 153 KB
PDF, 153 KB
droxidopa (Northera)
PDF, 183 KB
PDF, 183 KB
Dry Eye Medications
(Cequa | Lacrisert | Miebo | Restasis Multidose | Tyrvaya)
PDF, 164 KB
(Cequa | Lacrisert | Miebo | Restasis Multidose | Tyrvaya)
PDF, 164 KB
Duavee
PDF, 159 KB
PDF, 159 KB
Duchenne Muscular Dystrophy Medications (Medical)
(Amondys 45 | Exondys 51 | Viltepso | Vyondys 53)
PDF, 171 KB
(Amondys 45 | Exondys 51 | Viltepso | Vyondys 53)
PDF, 171 KB
Duopa (Medical)
PDF, 175 KB
PDF, 175 KB
Duopa (Pharmacy)
PDF, 145 KB
PDF, 145 KB
Dupixent
PDF, 288 KB
PDF, 288 KB
Durysta (Medical)
PDF, 171 KB
PDF, 171 KB
Duvyzat
PDF, 196 KB
PDF, 196 KB
Dysport (Botox Injections)
PDF, 219 KB
PDF, 219 KB
Egrifta
PDF, 155 KB
PDF, 155 KB
Elaprase IV (Medical)
PDF, 233 KB
PDF, 233 KB
Elevidys (Medical)
PDF, 195 KB
PDF, 195 KB
Empaveli (Medical)
PDF, 224 KB
PDF, 224 KB
Emsam
PDF, 140 KB
PDF, 140 KB
Emverm
PDF, 196 KB
PDF, 196 KB
Enbrel
PDF, 201 KB
PDF, 201 KB
Enjaymo (Medical)
PDF, 248 KB
PDF, 248 KB
Entyvio (Pharmacy)
PDF, 185 KB
PDF, 185 KB
Entyvio IV (Medical)
PDF, 195 KB
PDF, 195 KB
Eohilia
PDF, 181 KB
PDF, 181 KB
Epidiolex
PDF, 184 KB
PDF, 184 KB
Erectile Dysfunction
(Stendra | vardenafil (Levitra))
PDF, 169 KB
(Stendra | vardenafil (Levitra))
PDF, 169 KB
Erythropoiesis Stimulating Agents
Aranesp | Epogen | Mircera | Procrit | Retacrit
PDF, 564 KB
Aranesp | Epogen | Mircera | Procrit | Retacrit
PDF, 564 KB
ethacrynic acid (Edecrin)
PDF, 148 KB
PDF, 148 KB
Eucrisa
PDF, 217 KB
PDF, 217 KB
Evenity (Medical)
PDF, 218 KB
PDF, 218 KB
Evkeeza (Medical)
PDF, 226 KB
PDF, 226 KB
Evrysdi
PDF, 178 KB
PDF, 178 KB
Exxua
PDF, 203 KB
PDF, 203 KB
ezetimibe-simvastatin (Vytorin)
PDF, 159 KB
PDF, 159 KB
Fabhalta
PDF, 254 KB
PDF, 254 KB
Fasenra SQ (Medical)
PDF, 231 KB
PDF, 231 KB
Fasenra SQ (Pharmacy)
PDF, 231 KB
PDF, 231 KB
Filspari
PDF, 206 KB
PDF, 206 KB
Filsuvez
PDF, 195 KB
PDF, 195 KB
Fintepla
PDF, 216 KB
PDF, 216 KB
Firdapse
PDF, 170 KB
PDF, 170 KB
Flector Patch
PDF, 141 KB
PDF, 141 KB
flucytosine (Ancobon)
PDF, 152 KB
PDF, 152 KB
Furoscix
PDF, 162 KB
PDF, 162 KB
Galafold
PDF, 169 KB
PDF, 169 KB
Gastric Acid Suppression Drugs (Non-Preferred)
(dexlansoprazole | omeprazole/sodium bicarbonate | Voquezna)
PDF, 158 KB
(dexlansoprazole | omeprazole/sodium bicarbonate | Voquezna)
PDF, 158 KB
Gastrointestinal Motility Drugs
(Ibsrela | prucalopride (generic Motegrity) | Relistor | Trulance | Zelnorm)
PDF, 183 KB
(Ibsrela | prucalopride (generic Motegrity) | Relistor | Trulance | Zelnorm)
PDF, 183 KB
Gattex
PDF, 258 KB
PDF, 258 KB
Gaucher Disease Drugs (Enzyme Replacement Therapy) (Medical)
(Cerezyme | Elelyso | Vpriv)
PDF, 213 KB
(Cerezyme | Elelyso | Vpriv)
PDF, 213 KB
Gaucher Disease Drugs (Substrate Reduction Therapy) (Pharmacy)
(Cerdelga | Miglustat)
PDF, 222 KB
(Cerdelga | Miglustat)
PDF, 222 KB
Givlaari (Medical)
PDF, 228 KB
PDF, 228 KB
Glaucoma Drugs
(Betoptic-S | brimonidine 0.1% (Alphagan-P)| Rhopressa | Rocklatan | Simbrinza | tafluprost (Zioptan) | timolol (Betimol) | travoprost 0.004% (Travatan Z) | Vyzulta)
PDF, 144 KB
(Betoptic-S | brimonidine 0.1% (Alphagan-P)| Rhopressa | Rocklatan | Simbrinza | tafluprost (Zioptan) | timolol (Betimol) | travoprost 0.004% (Travatan Z) | Vyzulta)
PDF, 144 KB
Glucagon-like peptide (GLP-1) receptor agonists
(Bydureon Bcise | Byetta | Liraglutide | Mounjaro | Ozempic | Rybelsus | Trulicity)
PDF, 170 KB
(Bydureon Bcise | Byetta | Liraglutide | Mounjaro | Ozempic | Rybelsus | Trulicity)
PDF, 170 KB
glycopyrrolate (Cuvposa)
PDF, 186 KB
PDF, 186 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Medical)
(PREFERRED: Camcevi | Eligard (1-month, 3-month, 4-month, 6-month) | Lupron Depot (1-month, 3-month, 4-month, 6-month) | Trelstar (1-month, 3-month, 6-month) | Zoladex (1-month, 3-month) (Non-Preferred: Fensolvi | Supprelin LA | Triptodur)
PDF, 260 KB
(PREFERRED: Camcevi | Eligard (1-month, 3-month, 4-month, 6-month) | Lupron Depot (1-month, 3-month, 4-month, 6-month) | Trelstar (1-month, 3-month, 6-month) | Zoladex (1-month, 3-month) (Non-Preferred: Fensolvi | Supprelin LA | Triptodur)
PDF, 260 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Pharmacy)
(PREFERRED: Eligard | Leuprolide | Lupron Depot | Lupron Depot-Ped | Trelstar | Zoladex) (NON-PREFERRED: (Fensolvi | Supprelin LA | Synarel | Triptodur)
PDF, 256 KB
(PREFERRED: Eligard | Leuprolide | Lupron Depot | Lupron Depot-Ped | Trelstar | Zoladex) (NON-PREFERRED: (Fensolvi | Supprelin LA | Synarel | Triptodur)
PDF, 256 KB
Graft-Versus-Host Disease (GVHD) Drugs
(Jakafi | Imbruvica)
PDF, 202 KB
(Jakafi | Imbruvica)
PDF, 202 KB
Granulocyte Colony-Stimulating Factors (G-CSFs) (GM-CSF) (G-CSFs)
G-CSFs: (Granix | Neupogen | Nivestym | Nypozi | Releuko | Zarxio) GM-CSF: (Leukine) G-CSFs: (Fulphila | Fylnetra | Neulasta | Nyvepria | Rolvedon | Ryzneuta | Stimufend | Udenyca | Ziextenzo)
PDF, 206 KB
G-CSFs: (Granix | Neupogen | Nivestym | Nypozi | Releuko | Zarxio) GM-CSF: (Leukine) G-CSFs: (Fulphila | Fylnetra | Neulasta | Nyvepria | Rolvedon | Ryzneuta | Stimufend | Udenyca | Ziextenzo)
PDF, 206 KB
Grastek | Oralair
PDF, 171 KB
PDF, 171 KB
Hemangeol
PDF, 159 KB
PDF, 159 KB
Hemgenix (Medical)
PDF, 260 KB
PDF, 260 KB
Hemophilia Factors (IV) (Medical)
PDF, 162 KB
PDF, 162 KB
Hepatitis-C Antiviral (HCV) Drugs
(PREFERRED: sofosbuvir/elpatasvir | ledipasvir/sofobuvir | Mavyret) (NON-PREFERRED: Epclusa | Harvoni | Sovaldi | Viekira Pak | Vosevi | Zepatier)
PDF, 244 KB
(PREFERRED: sofosbuvir/elpatasvir | ledipasvir/sofobuvir | Mavyret) (NON-PREFERRED: Epclusa | Harvoni | Sovaldi | Viekira Pak | Vosevi | Zepatier)
PDF, 244 KB
Hyaluronate Acids (Medical)
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 242 KB
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 242 KB
Hyftor
PDF, 187 KB
PDF, 187 KB
Hympavzi (Medical)
PDF, 214 KB
PDF, 214 KB
Hympavzi (Pharmacy)
PDF, 201 KB
PDF, 201 KB
Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors (Medical)
Jesduvroq | Vafseo
PDF, 202 KB
Jesduvroq | Vafseo
PDF, 202 KB
icosapent ethyl (Vascepa)
PDF, 200 KB
PDF, 200 KB
iDose TR (Medical)
PDF, 176 KB
PDF, 176 KB
Ilaris (sJIA | AOSD) (Medical) (Non-Preferred)
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA) OR Adult Onset Still's Disease (AOSD)
PDF, 281 KB
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA) OR Adult Onset Still's Disease (AOSD)
PDF, 281 KB
Ilaris (TRAPS | HIDS/MKD | FMF diseases | CAPS) (Medical)
This form is applicable for the following diagnoses: Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF) and Cryopyrin-Associated Periodic Syndromes (CAPS)
PDF, 241 KB
This form is applicable for the following diagnoses: Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF) and Cryopyrin-Associated Periodic Syndromes (CAPS)
PDF, 241 KB
Ilumya (Pharmacy)
PDF, 168 KB
PDF, 168 KB
Ilumya SQ (Medical)
(Ilumya should ONLY be administered by a healthcare provider)
PDF, 172 KB
(Ilumya should ONLY be administered by a healthcare provider)
PDF, 172 KB
Imcivree
PDF, 200 KB
PDF, 200 KB
Immune Globulin Intravenous (IVIG) (immunodeficiency) (CIDP) (Medical)
(Chronic Inflammatory Demyelinating Polyneuropathy)
PDF, 239 KB
(Chronic Inflammatory Demyelinating Polyneuropathy)
PDF, 239 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Disorders) (Medical)
(Miscellaneous Disorders)
PDF, 275 KB
(Miscellaneous Disorders)
PDF, 275 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Sjögren’s Syndrome Neuropathies) (Medical)
(Miscellaneous Sjögren’s Syndrome Neuropathies)
PDF, 271 KB
(Miscellaneous Sjögren’s Syndrome Neuropathies)
PDF, 271 KB
Immune Globulin Intravenous (IVIG) (Multifocal Motor Neuropathy (MMN)) (Medical)
(Multifocal Motor Neuropathy (MMN))
PDF, 229 KB
(Multifocal Motor Neuropathy (MMN))
PDF, 229 KB
Immune Globulin Intravenous (IVIG) (Primary Immunodeficiency Disorder (PID)) (Medical)
(Asceniv | Bivigam | Carimune NF | Flebogamma DIF | Gammagard | Gammaked | Gammaplex | Gamunex-C | Octagam | Panzyga | Privigen)
PDF, 235 KB
(Asceniv | Bivigam | Carimune NF | Flebogamma DIF | Gammagard | Gammaked | Gammaplex | Gamunex-C | Octagam | Panzyga | Privigen)
PDF, 235 KB
Immune Globulin SQ (Primary Immunodeficiency Disorder) (Medical)
(Cutaquiq | Cuvitru | Gammagard | Gammunex-C | Hizentra | Hyqvia | Xembify)
PDF, 247 KB
(Cutaquiq | Cuvitru | Gammagard | Gammunex-C | Hizentra | Hyqvia | Xembify)
PDF, 247 KB
Increlex
PDF, 176 KB
PDF, 176 KB
Infertility Drugs
(cetrotide| Crinone | Follistim | Gonal-F | Novarel | clomiphene citrate | Endometrin | Fyremadel | Ovidrel | chorionic gonadotropin | First-progesterone vaginal suppository | ganirelix acetate | Menopur | Pregnyl)
PDF, 140 KB
(cetrotide| Crinone | Follistim | Gonal-F | Novarel | clomiphene citrate | Endometrin | Fyremadel | Ovidrel | chorionic gonadotropin | First-progesterone vaginal suppository | ganirelix acetate | Menopur | Pregnyl)
PDF, 140 KB
Inflammatory Bowel Disease (IBD) Drugs
(Mesalamine DR 800 mg | Dipentum | budesonide ER 9mg)
PDF, 163 KB
(Mesalamine DR 800 mg | Dipentum | budesonide ER 9mg)
PDF, 163 KB
Infliximab Category (Medical)
(PREFERRED: Renflexis | Infliximab) (Non-Preferred: Avsola | Inflectra | Remicade | Zymfentra)
PDF, 242 KB
(PREFERRED: Renflexis | Infliximab) (Non-Preferred: Avsola | Inflectra | Remicade | Zymfentra)
PDF, 242 KB
Ingrezza
PDF, 188 KB
PDF, 188 KB
Inpefa
PDF, 145 KB
PDF, 145 KB
Insomnia Drugs
(Belsomra | Dayvigo |doxepin | quazepam (Doral) | Quviviq | ramelteon (Rozerem))PDF, 161 KB
(Belsomra | Dayvigo |doxepin | quazepam (Doral) | Quviviq | ramelteon (Rozerem))PDF, 161 KB
Insulins (Non-Preferred)
(NON-PREFERRED: Admelog | Apidra | Basaglar | Fiasp | insulin aspart | insulin aspart protamine 70/30 | insulin degludec | insulin glargine vial/SoloStar | insulin glargine Solostar/Max Solostar | insulin lispro | insulin lispro JR | insulin lispro 75/25 mix Kwikpen | Levemir | Lyumjev | Novolin 70/30 | Novolin N | Novolin R | Novolog | NovoLOG Mix 70/30 | Semglee )
PDF, 174 KB
(NON-PREFERRED: Admelog | Apidra | Basaglar | Fiasp | insulin aspart | insulin aspart protamine 70/30 | insulin degludec | insulin glargine vial/SoloStar | insulin glargine Solostar/Max Solostar | insulin lispro | insulin lispro JR | insulin lispro 75/25 mix Kwikpen | Levemir | Lyumjev | Novolin 70/30 | Novolin N | Novolin R | Novolog | NovoLOG Mix 70/30 | Semglee )
PDF, 174 KB
Isturisa
PDF, 192 KB
PDF, 192 KB
IV tocilizumab Products (Medical)
(Preferred: Actemra IV | Tyenne IV) (Non-Preferred: Tofidence IV)
PDF, 246 KB
(Preferred: Actemra IV | Tyenne IV) (Non-Preferred: Tofidence IV)
PDF, 246 KB
Ivermectin (Stromectol) tablets
PDF, 128 KB
PDF, 128 KB
Joenja
PDF, 195 KB
PDF, 195 KB
Juxtapid
PDF, 179 KB
PDF, 179 KB
Jynarque
PDF, 282 KB
PDF, 282 KB
Kalbitor (Medical)
PDF, 213 KB
PDF, 213 KB
Kalydeco
PDF, 180 KB
PDF, 180 KB
Kanuma (Medical)
PDF, 214 KB
PDF, 214 KB
Kebilidi (Medical)
PDF, 213 KB
PDF, 213 KB
Kerendia
PDF, 219 KB
PDF, 219 KB
Kevzara
PDF, 171 KB
PDF, 171 KB
Kineret
PDF, 274 KB
PDF, 274 KB
Kisunla (Medical)
PDF, 400 KB
PDF, 400 KB
Korlym
PDF, 168 KB
PDF, 168 KB
Korsuva (Medical)
PDF, 200 KB
PDF, 200 KB
Krystexxa (Medical)
PDF, 248 KB
PDF, 248 KB
Kymriah (Medical)
PDF, 253 KB
PDF, 253 KB
Lampit | benznidazole
PDF, 172 KB
PDF, 172 KB
Lamzede (Medical)
PDF, 184 KB
PDF, 184 KB
Lantidra (Medical)
PDF, 200 KB
PDF, 200 KB
Lemtrada IV (Medical)
PDF, 171 KB
PDF, 171 KB
Lenmeldy (Medical)
PDF, 272 KB
PDF, 272 KB
Leqembi (Medical)
PDF, 726 KB
PDF, 726 KB
Leqvio (Medical)
PDF, 259 KB
PDF, 259 KB
L-glutamine (Endari)
PDF, 162 KB
PDF, 162 KB
Libervant | Nayzilam | Valtoco
PDF, 167 KB
PDF, 167 KB
Litfulo
PDF, 163 KB
PDF, 163 KB
Livmarli
PDF, 233 KB
PDF, 233 KB
Livtencity
PDF, 253 KB
PDF, 253 KB
Lodoco
PDF, 171 KB
PDF, 171 KB
Long-Acting Antimuscarinic (LAMA) and Long-Acting Beta2 Agonist (LABA) Combination Products
Bevespi Aerosphere | Breztri | Duaklir Pressair
PDF, 180 KB
Bevespi Aerosphere | Breztri | Duaklir Pressair
PDF, 180 KB
Long-Acting Beta2 Agonist (LABA) and Inhaled Corticosteroid (ICS) Combination Products
Advair Diskus | AirDuo Digihaler | AirDuo RespiClick | fluticasone furoate-vilanterol | Symbicort
PDF, 166 KB
Advair Diskus | AirDuo Digihaler | AirDuo RespiClick | fluticasone furoate-vilanterol | Symbicort
PDF, 166 KB
Long-Acting Muscarinic Antagonist (LAMA) Anticholinergic Inhalers
Tudorza Pressair | Yupelri
PDF, 178 KB
Tudorza Pressair | Yupelri
PDF, 178 KB
Lumizyme (Medical)
PDF, 196 KB
PDF, 196 KB
Lupkynis
PDF, 197 KB
PDF, 197 KB
Luxturna (Medical)
(Medication should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in intraocular surgery.)
PDF, 170 KB
(Medication should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in intraocular surgery.)
PDF, 170 KB
Lyfgenia (Medical)
PDF, 264 KB
PDF, 264 KB
Lyrica CR
PDF, 166 KB
PDF, 166 KB
Macular Degeneration Drugs (Medical)
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Lucentis | Pavblu | Susvimo | Vabysmo)
PDF, 245 KB
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Lucentis | Pavblu | Susvimo | Vabysmo)
PDF, 245 KB
Marplan
PDF, 136 KB
PDF, 136 KB
Mepsevii IV (Medical)
PDF, 177 KB
PDF, 177 KB
Metaxalone
PDF, 150 KB
PDF, 150 KB
mifepristone 200 mg (Mifeprex)
PDF, 149 KB
PDF, 149 KB
mifepristone 300 mg (Korlym)
PDF, 169 KB
PDF, 169 KB
Migraine Treatment: Injectable Calcitonin Gene-Related Peptide (CGRP) Antagonists
(PREFERRED: Aimovig l Emgality) (NON-PREFERRED: Ajovy)
PDF, 206 KB
(PREFERRED: Aimovig l Emgality) (NON-PREFERRED: Ajovy)
PDF, 206 KB
Migraine Treatment: Non-Injectable drugs
(PREFERRED: Nurtec ODT | Qulipta) (Non-Preferred: Reyvow | Ubrelvy | Zavzpret)
PDF, 215 KB
(PREFERRED: Nurtec ODT | Qulipta) (Non-Preferred: Reyvow | Ubrelvy | Zavzpret)
PDF, 215 KB
Miplyffa
PDF, 187 KB
PDF, 187 KB
Mulpleta
PDF, 192 KB
PDF, 192 KB
Multiple Sclerosis Drugs
(Bafiertam | Extavia | Gilenya 0.5mg | Kesimpta | Mavenclad | Mayzent | Ponvory | Vumerity | Zeposia)
PDF, 200 KB
(Bafiertam | Extavia | Gilenya 0.5mg | Kesimpta | Mavenclad | Mayzent | Ponvory | Vumerity | Zeposia)
PDF, 200 KB
Myalept
PDF, 180 KB
PDF, 180 KB
Myfembree | Oriahnn
PDF, 166 KB
PDF, 166 KB
Myobloc
PDF, 161 KB
PDF, 161 KB
Myobloc (Medical)
Botulinum Toxin Injections, Type B (Myobloc) (Cosmetic indications Excluded)
PDF, 168 KB
Botulinum Toxin Injections, Type B (Myobloc) (Cosmetic indications Excluded)
PDF, 168 KB
Mytesi (formerly FULYZAQ)
PDF, 181 KB
PDF, 181 KB
Naglazyme (Medical)
PDF, 201 KB
PDF, 201 KB
Nasal Corticosteroids
(azelastine HCl-fluticasone propionate (Dymista) | Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)
PDF, 213 KB
(azelastine HCl-fluticasone propionate (Dymista) | Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)
PDF, 213 KB
Natpara
PDF, 197 KB
PDF, 197 KB
Nemluvio
PDF, 169 KB
PDF, 169 KB
Nexletol | Nexlizet
PDF, 263 KB
PDF, 263 KB
Nexviazyme | Pombiliti (Medical)
PDF, 255 KB
PDF, 255 KB
Niktimvo (Medical)
PDF, 224 KB
PDF, 224 KB
nitazoxanide (Alinia)
PDF, 151 KB
PDF, 151 KB
Nocdurna
PDF, 156 KB
PDF, 156 KB
Noninfectious Uveitis (NIU) Drugs (Medical)
(Retisert | Yutiq)
PDF, 232 KB
(Retisert | Yutiq)
PDF, 232 KB
Non-Preferred inhaled Corticosteroids (ICS)
(Alvesco | ArmonAir Digihaler | Asmanex | Flovent Diskus/HFA | fluticasone propionate Diskus/HFA)
PDF, 166 KB
(Alvesco | ArmonAir Digihaler | Asmanex | Flovent Diskus/HFA | fluticasone propionate Diskus/HFA)
PDF, 166 KB
Nplate (Medical)
PDF, 236 KB
PDF, 236 KB
Nuedexta
PDF, 154 KB
PDF, 154 KB
Nulibry (Medical)
PDF, 243 KB
PDF, 243 KB
Nulibry (Pharmacy)
PDF, 234 KB
PDF, 234 KB
Nulojix (Medical)
PDF, 213 KB
PDF, 213 KB
Nuplazid
PDF, 198 KB
PDF, 198 KB
Ocular Antihistamines
(Alocril | Alomide | bepotastine besilate 1.5% (Bepreve) | Lastacaft | Zerviate)
PDF, 136 KB
(Alocril | Alomide | bepotastine besilate 1.5% (Bepreve) | Lastacaft | Zerviate)
PDF, 136 KB
OFEV
PDF, 253 KB
PDF, 253 KB
Ohtuvayre
PDF, 195 KB
PDF, 195 KB
Olumiant
PDF, 177 KB
PDF, 177 KB
Omisirge (Medical)
PDF, 228 KB
PDF, 228 KB
Omvoh
PDF, 255 KB
PDF, 255 KB
Opfolda
PDF, 203 KB
PDF, 203 KB
Ophthalmic Corticosteroid Injections (Medical)
(Ozurdex | Iluvien | Xipere)
PDF, 232 KB
(Ozurdex | Iluvien | Xipere)
PDF, 232 KB
Opioids - Commercial Only
PDF, 232 KB
PDF, 232 KB
Opzelura
PDF, 146 KB
PDF, 146 KB
Orencia SQ (Pharmacy)
PDF, 180 KB
PDF, 180 KB
Orfadin | Nityr | nitisinone
PDF, 163 KB
PDF, 163 KB
Orilissa
PDF, 164 KB
PDF, 164 KB
Orkambi
PDF, 219 KB
PDF, 219 KB
Osphena
PDF, 131 KB
PDF, 131 KB
Otezla
PDF, 221 KB
PDF, 221 KB
Otrexup | Rasuvo | Reditrex
PDF, 130 KB
PDF, 130 KB
Overactive Bladder Drugs
( fesoterodine (Toviaz) | Gemtesa | mirabegron (Myrbetriq))
PDF, 165 KB
( fesoterodine (Toviaz) | Gemtesa | mirabegron (Myrbetriq))
PDF, 165 KB
Oxbryta
PDF, 218 KB
PDF, 218 KB
Oxervate
PDF, 207 KB
PDF, 207 KB
Oxlumo | Rivfloza (Medical)
PDF, 217 KB
PDF, 217 KB
Palforzia
PDF, 228 KB
PDF, 228 KB
Palynziq Injection
PDF, 201 KB
PDF, 201 KB
Pancreatic Enzymes
(PREFERRED - Creon | Zenpep) (Non-Preferred - Pancreaze | Pertzye | Ultresa | Viokace)
PDF, 150 KB
(PREFERRED - Creon | Zenpep) (Non-Preferred - Pancreaze | Pertzye | Ultresa | Viokace)
PDF, 150 KB
Panretin
PDF, 163 KB
PDF, 163 KB
Parathyroid Hormone Analogs
teriparatide (Forteo) | Tymlos | teriparatide
PDF, 180 KB
teriparatide (Forteo) | Tymlos | teriparatide
PDF, 180 KB
penciclovir (Denavir)
PDF, 153 KB
PDF, 153 KB
Phosphate Binders
Auryxia | lanthanum chewable tablet (Fosrenol) | Velphoro
PDF, 147 KB
Auryxia | lanthanum chewable tablet (Fosrenol) | Velphoro
PDF, 147 KB
pimecrolimus (Elidel)
PDF, 152 KB
PDF, 152 KB
pirfenidone (Esbriet)
PDF, 183 KB
PDF, 183 KB
pitavastatin (Livalo) | Zypitamag
PDF, 154 KB
PDF, 154 KB
plerixafor (Mozobil) (Medical)
PDF, 205 KB
PDF, 205 KB
Pradaxa
PDF, 197 KB
PDF, 197 KB
Praluent | Repatha
PDF, 253 KB
PDF, 253 KB
Pretomanid
PDF, 175 KB
PDF, 175 KB
Prevymis IV (Medical)
PDF, 198 KB
PDF, 198 KB
Prialt (Medical)
PDF, 143 KB
PDF, 143 KB
Primary Biliary Cholangitis Drugs
Iqirvo | Livdelzi | Ocaliva
PDF, 215 KB
Iqirvo | Livdelzi | Ocaliva
PDF, 215 KB
Procysbi
PDF, 167 KB
PDF, 167 KB
Prophylaxis Hereditary Angiodema Drugs (Medical)
(Cinryze | Haegarda | Takhzyro)
PDF, 253 KB
(Cinryze | Haegarda | Takhzyro)
PDF, 253 KB
Prophylaxis Hereditary Angiodema Drugs (Pharmacy)
(Cinryze | Haegarda | Orladeyo | Takhzyro)
PDF, 204 KB
(Cinryze | Haegarda | Orladeyo | Takhzyro)
PDF, 204 KB
Pulmonary Arterial Hypertension Drugs (Medical)
(sildenafil IV | epoprostenol IV | treprostinil IV | Uptravi IV)
PDF, 247 KB
(sildenafil IV | epoprostenol IV | treprostinil IV | Uptravi IV)
PDF, 247 KB
Pulmonary Arterial Hypertension Drugs (Pharmacy)
(sildenafil 20mg | sildenafil oral suspension | tadalafil 20mg | Tadliq | ambrisentan | bosentan | Opsumit | Tracleer dispersible tablet | Adempas | Orenitram | Tyvaso | Tyvaso DPI | Uptravi | Ventavis)
PDF, 267 KB
(sildenafil 20mg | sildenafil oral suspension | tadalafil 20mg | Tadliq | ambrisentan | bosentan | Opsumit | Tracleer dispersible tablet | Adempas | Orenitram | Tyvaso | Tyvaso DPI | Uptravi | Ventavis)
PDF, 267 KB
Pulmozyme
PDF, 203 KB
PDF, 203 KB
pyrimethamine (Daraprim)
PDF, 229 KB
PDF, 229 KB
Pyrukynd
PDF, 195 KB
PDF, 195 KB
Qalsody (Medical)
PDF, 253 KB
PDF, 253 KB
Qbrexza
PDF, 177 KB
PDF, 177 KB
Qelbree
PDF, 153 KB
PDF, 153 KB
Radicava ORS
PDF, 196 KB
PDF, 196 KB
Ragwitek
PDF, 167 KB
PDF, 167 KB
Ravicti
PDF, 170 KB
PDF, 170 KB
Rayaldee
PDF, 195 KB
PDF, 195 KB
Reblozyl (Medical)
PDF, 270 KB
PDF, 270 KB
Rebyota (Medical)
PDF, 203 KB
PDF, 203 KB
Recombinant Growth Hormone (rhGH)
(PREFERRED: Omnitrope | Norditropin) (NON-PREFERRED: Genotropin | Humatrope | *Ngnela | Nutropin | Nutropin AQ | Saizen | Sogroya | *Skytrofa | Zomacton) (*For use in members < 18 years of age)
PDF, 181 KB
(PREFERRED: Omnitrope | Norditropin) (NON-PREFERRED: Genotropin | Humatrope | *Ngnela | Nutropin | Nutropin AQ | Saizen | Sogroya | *Skytrofa | Zomacton) (*For use in members < 18 years of age)
PDF, 181 KB
Recorlev
PDF, 193 KB
PDF, 193 KB
Relyvrio
PDF, 186 KB
PDF, 186 KB
Revcovi (Pharmacy)
PDF, 231 KB
PDF, 231 KB
Rezdiffra
PDF, 194 KB
PDF, 194 KB
Rezurock
PDF, 160 KB
PDF, 160 KB
Rezzayo (Medical)
PDF, 193 KB
PDF, 193 KB
Rinvoq | Rinvoq LQ
PDF, 240 KB
PDF, 240 KB
Roctavian (Medical)
PDF, 234 KB
PDF, 234 KB
roflumilast (generic Daliresp)
PDF, 164 KB
PDF, 164 KB
Ruconest (Pharmacy)
PDF, 231 KB
PDF, 231 KB
Ryplazim (Medical)
PDF, 223 KB
PDF, 223 KB
Rystiggo (Medical)
PDF, 185 KB
PDF, 185 KB
Saphnelo (Medical)
PDF, 235 KB
PDF, 235 KB
Sapropterin Products
sapropterin dihydrochloride (generic Kuvan) │ Javygtor
PDF, 184 KB
sapropterin dihydrochloride (generic Kuvan) │ Javygtor
PDF, 184 KB
Savaysa
PDF, 173 KB
PDF, 173 KB
Savella
PDF, 154 KB
PDF, 154 KB
Scenesse (Medical)
PDF, 211 KB
PDF, 211 KB
Serostim
PDF, 162 KB
PDF, 162 KB
Seysara
PDF, 146 KB
PDF, 146 KB
Siliq Injection (Pharmacy)
PDF, 168 KB
PDF, 168 KB
Simponi SQ (Pharmacy)
PDF, 182 KB
PDF, 182 KB
Sirturo
PDF, 167 KB
PDF, 167 KB
Skyclarys
PDF, 194 KB
PDF, 194 KB
Skysona (Medical)
PDF, 255 KB
PDF, 255 KB
Sodium Oxybate Products
(Lumryz ER oral suspension | Sodium Oxybate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 231 KB
(Lumryz ER oral suspension | Sodium Oxybate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 231 KB
Sodium Phenylbutyrate Products
(sodium phenylbutyrate (Buphenyl) powder/tablets | Olpruva oral suspension | Pheburane oral suspension)
PDF, 187 KB
(sodium phenylbutyrate (Buphenyl) powder/tablets | Olpruva oral suspension | Pheburane oral suspension)
PDF, 187 KB
Sodium-glucose Cotransporter-2 Inhibitor (SGLT2) Drugs (Non-Preferred)
(Brenzavvy| Invokana | Invokamet/XR | Qtern | Segluromet | Steglatro | Steguljan|Segluromet)
PDF, 163 KB
(Brenzavvy| Invokana | Invokamet/XR | Qtern | Segluromet | Steglatro | Steguljan|Segluromet)
PDF, 163 KB
Sohonos
PDF, 173 KB
PDF, 173 KB
Soliqua | Xultophy
PDF, 161 KB
PDF, 161 KB
Somatostatin Analog Drugs (Medical)
(lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection | Somatuline Depot injection)
PDF, 196 KB
(lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection | Somatuline Depot injection)
PDF, 196 KB
Somatostatin Analog Drugs (Pharmacy)
(Bynfezia | Mycapssa | Sandostatin LAR Depot | Signafor | Somavert)
PDF, 231 KB
(Bynfezia | Mycapssa | Sandostatin LAR Depot | Signafor | Somavert)
PDF, 231 KB
Sotyktu
PDF, 170 KB
PDF, 170 KB
Spevigo (Medical)
PDF, 234 KB
PDF, 234 KB
Spevigo SQ
PDF, 228 KB
PDF, 228 KB
Spinraza (Medical)
(Medication provided by Physician's office)
PDF, 273 KB
(Medication provided by Physician's office)
PDF, 273 KB
Spravato
PDF, 180 KB
PDF, 180 KB
SQ tocilizumab Products - Giant Cell Arteritis (GCA)
Actemra SQ | Tyenne SQ
PDF, 204 KB
Actemra SQ | Tyenne SQ
PDF, 204 KB
SQ tocilizumab Products (Pharmacy)
Actemra SQ | Tyenne SQ
PDF, 207 KB
Actemra SQ | Tyenne SQ
PDF, 207 KB
Strensiq
PDF, 205 KB
PDF, 205 KB
Sucraid
PDF, 168 KB
PDF, 168 KB
Sunlenca
PDF, 219 KB
PDF, 219 KB
Sunlenca (Medical)
PDF, 226 KB
PDF, 226 KB
Sunosi
PDF, 192 KB
PDF, 192 KB
Symdeko
PDF, 200 KB
PDF, 200 KB
Synagis
PDF, 894 KB
PDF, 894 KB
Syndros Oral Solution
PDF, 199 KB
PDF, 199 KB
Taltz SQ
PDF, 231 KB
PDF, 231 KB
Tarpeyo
PDF, 198 KB
PDF, 198 KB
tasimelteon (Hetlioz)
PDF, 194 KB
PDF, 194 KB
Tavalisse
PDF, 222 KB
PDF, 222 KB
Tavneos
PDF, 194 KB
PDF, 194 KB
Tecartus (Medical)
PDF, 220 KB
PDF, 220 KB
Tecelra (Medical)
PDF, 236 KB
PDF, 236 KB
Tepezza (Medical)
PDF, 234 KB
PDF, 234 KB
Testosterone Replacement Therapy - TRT (Pharmacy)
(PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution | Kyzatrex) (NON-PREFERRED - Androderm | Natesto | Vogelxo 1%)
PDF, 219 KB
(PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution | Kyzatrex) (NON-PREFERRED - Androderm | Natesto | Vogelxo 1%)
PDF, 219 KB
Testosterone Replacement Therapy Injectable (Medical)
(Aveed | Azmiro | TestoPel) Medication being provided by the physician's office
PDF, 251 KB
(Aveed | Azmiro | TestoPel) Medication being provided by the physician's office
PDF, 251 KB
tetrabenazine (Xenazine)
PDF, 154 KB
PDF, 154 KB
Tezspire (Medical)
PDF, 228 KB
PDF, 228 KB
Tezspire (Pharmacy)
PDF, 234 KB
PDF, 234 KB
Tiglutik
PDF, 162 KB
PDF, 162 KB
Tobi Podhaler
PDF, 166 KB
PDF, 166 KB
tolvaptan (Samsca)
PDF, 166 KB
PDF, 166 KB
Topical Acne Drugs
(PREFERRED: adapalene (generic Differin) | tretinoin (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel | Altreno | Aklief | Amzeeq | Azelex | clindamycin1.2%/benzoyl peroxide 2.5% (genderic Acanya) | dapsone gel 5% (generic Aczone) | erythromycin 3%/ benzoyl peroxide 5% (generic Benzamycin) | Retin-A Micro 0.06%, 0.08% gel | tazarotene (generic Fabior) foam 0.1% | tretinoin gel 0.05% (generic Atralin) | tretinoin microsphere (generic Retin-A Micro) | Winlevi)
PDF, 215 KB
(PREFERRED: adapalene (generic Differin) | tretinoin (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel | Altreno | Aklief | Amzeeq | Azelex | clindamycin1.2%/benzoyl peroxide 2.5% (genderic Acanya) | dapsone gel 5% (generic Aczone) | erythromycin 3%/ benzoyl peroxide 5% (generic Benzamycin) | Retin-A Micro 0.06%, 0.08% gel | tazarotene (generic Fabior) foam 0.1% | tretinoin gel 0.05% (generic Atralin) | tretinoin microsphere (generic Retin-A Micro) | Winlevi)
PDF, 215 KB
Topical Antibiotics
(Altabax 1% ointment | Xepi 1% cream)
PDF, 138 KB
(Altabax 1% ointment | Xepi 1% cream)
PDF, 138 KB
Topical Antifungals
(Ertaczo | luliconazole (Luzu) | Mentax | naftifine (Naftin) | oxiconazole (Oxistat) | sulconazole (Exelderm))
PDF, 148 KB
(Ertaczo | luliconazole (Luzu) | Mentax | naftifine (Naftin) | oxiconazole (Oxistat) | sulconazole (Exelderm))
PDF, 148 KB
Topical Corticosteroids
(amcinonide 0.1% | betamethasone valerate 0.12% foam | calcipotriene/betamethasone | Capex Shampoo | clobetasol proprionate | clocortolone pivalate | Cordran Tape | dexoximetasone 0.05% and 0.25% | diflorasone 0.05% | fluocinonide 0.1% cream | flurandrenolide 0.05% | fluticasone 0.05% | Impoyz | Texacort | triamcinolone spray)
PDF, 174 KB
(amcinonide 0.1% | betamethasone valerate 0.12% foam | calcipotriene/betamethasone | Capex Shampoo | clobetasol proprionate | clocortolone pivalate | Cordran Tape | dexoximetasone 0.05% and 0.25% | diflorasone 0.05% | fluocinonide 0.1% cream | flurandrenolide 0.05% | fluticasone 0.05% | Impoyz | Texacort | triamcinolone spray)
PDF, 174 KB
Topical Immunomodulators
(Zyclara | imiquimod 3.75% packets/pump | Picato | Klisyri)
PDF, 180 KB
(Zyclara | imiquimod 3.75% packets/pump | Picato | Klisyri)
PDF, 180 KB
Topical Rosacea Drugs
(brimonidine (Mirvaso) | Rhofade | ivermectin (Soolantra) | Zilxi)
PDF, 164 KB
(brimonidine (Mirvaso) | Rhofade | ivermectin (Soolantra) | Zilxi)
PDF, 164 KB
Topical Zoryve Products
Zoryve 0.15% cream│ Zoryve 0.3% cream │ Zoryve 0.3% topical foam
PDF, 199 KB
Zoryve 0.15% cream│ Zoryve 0.3% cream │ Zoryve 0.3% topical foam
PDF, 199 KB
Transthyretin Stabilizers
Attruby | Vyndamax | Vyndaqel
PDF, 183 KB
Attruby | Vyndamax | Vyndaqel
PDF, 183 KB
Trikafta
PDF, 201 KB
PDF, 201 KB
Trogarzo IV (Medical)
(Medication will be provided by the Physician's office.)
PDF, 165 KB
(Medication will be provided by the Physician's office.)
PDF, 165 KB
Tryngolza
PDF, 177 KB
PDF, 177 KB
Tryvio
PDF, 156 KB
PDF, 156 KB
Tysabri IV (Medical)
PDF, 223 KB
PDF, 223 KB
Tyvaso (PH-ILD)
PDF, 197 KB
PDF, 197 KB
Tzield (Medical)
PDF, 252 KB
PDF, 252 KB
Uloric
PDF, 133 KB
PDF, 133 KB
Unituxin (Medical)
PDF, 213 KB
PDF, 213 KB
Upneeq
PDF, 208 KB
PDF, 208 KB
Vecamyl
PDF, 149 KB
PDF, 149 KB
Velsipity
PDF, 199 KB
PDF, 199 KB
Vemlidy
PDF, 176 KB
PDF, 176 KB
Veopoz (Medical)
PDF, 218 KB
PDF, 218 KB
Veozah
PDF, 156 KB
PDF, 156 KB
Verquvo
PDF, 159 KB
PDF, 159 KB
Vigabatrin Products
Sabril | Vigadrone | vigabatrin | Vigafyde | Vigpoder
PDF, 176 KB
Sabril | Vigadrone | vigabatrin | Vigafyde | Vigpoder
PDF, 176 KB
Vijoice
PDF, 189 KB
PDF, 189 KB
Vimizim IV (Medical)
(IV Infusion performed ONLY at Sentara Infusion Centers.)
PDF, 216 KB
(IV Infusion performed ONLY at Sentara Infusion Centers.)
PDF, 216 KB
Visudyne (Medical)
PDF, 190 KB
PDF, 190 KB
Vivjoa
PDF, 227 KB
PDF, 227 KB
Vowst
PDF, 201 KB
PDF, 201 KB
Voxzogo
PDF, 196 KB
PDF, 196 KB
Voydeya
PDF, 225 KB
PDF, 225 KB
Vtama
PDF, 195 KB
PDF, 195 KB
Vyalev (Medical)
PDF, 174 KB
PDF, 174 KB
Vyalev (Pharmacy)
PDF, 157 KB
PDF, 157 KB
Vyepti (Medical)
PDF, 226 KB
PDF, 226 KB
Vyjuvek (Medical)
PDF, 227 KB
PDF, 227 KB
Vyleesi
PDF, 154 KB
PDF, 154 KB
Vyvanse (Binge Eating Disorder)
PDF, 190 KB
PDF, 190 KB
Vyvgart_Vyvgart Hytrulo (Medical)
PDF, 218 KB
PDF, 218 KB
Wainua
PDF, 233 KB
PDF, 233 KB
Wakix
PDF, 241 KB
PDF, 241 KB
Weight Management Drugs (Group Specific Benefit)
(benzphetamine 50 mg | Contrave | diethylpropion IR/ER | Lomaira | phendimetrazine IR | phentermine HCL | Qsymia | Saxenda | Wegovy | Xenical | Zepbound)
PDF, 176 KB
(benzphetamine 50 mg | Contrave | diethylpropion IR/ER | Lomaira | phendimetrazine IR | phentermine HCL | Qsymia | Saxenda | Wegovy | Xenical | Zepbound)
PDF, 176 KB
Winrevair
PDF, 275 KB
PDF, 275 KB
Xacduro (Medical)
PDF, 222 KB
PDF, 222 KB
Xdemvy
PDF, 156 KB
PDF, 156 KB
Xeljanz | Xeljanz XR
PDF, 218 KB
PDF, 218 KB
Xenleta (Medical)
PDF, 168 KB
PDF, 168 KB
Xenleta (Pharmacy)
PDF, 134 KB
PDF, 134 KB
Xenpozyme (Medical)
PDF, 237 KB
PDF, 237 KB
Xiaflex (Medical)
PDF, 205 KB
PDF, 205 KB
Xifaxan
PDF, 180 KB
PDF, 180 KB
Xolair (Medical)
PDF, 619 KB
PDF, 619 KB
Xolair (Pharmacy)
PDF, 594 KB
PDF, 594 KB
Xolremdi
PDF, 227 KB
PDF, 227 KB
Xphozah
PDF, 166 KB
PDF, 166 KB
Ycanth (Medical)
PDF, 165 KB
PDF, 165 KB
Yescarta (Medical)
PDF, 215 KB
PDF, 215 KB
Yorvipath
PDF, 196 KB
PDF, 196 KB
Zeposia
PDF, 196 KB
PDF, 196 KB
Zilbrysq
PDF, 208 KB
PDF, 208 KB
Zinplava (Medical)
PDF, 232 KB
PDF, 232 KB
Zokinvy
PDF, 191 KB
PDF, 191 KB
Zolgensma IV (Medical)
PDF, 278 KB
PDF, 278 KB
zolmitriptan (Zomig) Nasal Spray
PDF, 155 KB
PDF, 155 KB
Zontivity
PDF, 181 KB
PDF, 181 KB
Zorbtive
PDF, 186 KB
PDF, 186 KB
Ztalmy
PDF, 144 KB
PDF, 144 KB
Zulresso Injection (Medical)
(Behavioral Health Medical)
PDF, 173 KB
(Behavioral Health Medical)
PDF, 173 KB
Zurzuvae
PDF, 161 KB
PDF, 161 KB
Zyflo | Zileuton ER
PDF, 137 KB
PDF, 137 KB
Zymfentra
PDF, 190 KB
PDF, 190 KB
Zynteglo (Medical)
PDF, 232 KB
PDF, 232 KB