Prescription Drug Forms

Drug

Prior Authorization

5 HI1 Agonist Post Limit
AAT Deficiency (Medical)
Abecma® (Medical)
Abraxane® (Medical)
Abstral®
Acne Products Combinations Topical Limit
Actemra® MR (Medical)
Actemra® (Pharmacy)
Acthar Gel Purified Cortrophin LI® (Medical)
Actimmune® (Medical)
Actimmune® (Pharmacy)
Actiq®
Adagen®
Adakveo®
Adcetris®
Adcirca®
Adempas®
Afstyla®
ADHD Agents Post Limit
Afinitor®, Afinitor Disperz®
Aldurazyme® (Medical)
Aldurazyme® (Pharmacy)
Alecensa®
Alimta®
Aliqopa™
Amondys 45®
Alphanate®, Humate-P,®, Koate-DVI®, Wilate® (Medical)
Alsuma®
Alunbrig®
Amerge®, Imitrex®, Maxalt®, Zomig®
Ampyra®
Antidiabetic Agents Step Therapy
Antiemetics Post Limit
Antifungal Topical Step Therapy (HMF)
Apokyn®, Kynmobi®
Aranesp®
Arcalyst®
Arikayce®
Arzerra®
Asparlas®
Atacand®
Atralin®
Atypical Antipsychotics®
Aubagio®
Austedo®
Avastin®, Mvasi®, Zirabev® MR (Medical)
Aveed®
Avita®
Avonex®
Avsola ® (Medical)
Ayvakit™ ACSF (Pharmacy)
Balversa®
Bavencio® (Medical)
Bebulin VH®
Benlysta® IV SGM (Medical)
Benlysta® (Pharmacy)
Beovu® (Medical)
Berinert® (Medical)
Berinert® (Pharmacy)
Besponsa™
Bethkis®
Bexarotene®
Bivigam®
Blenrep®
Blincyto® (Medical)
Bosulif®
Botox®
Braftovi ® (Pharmacy)
Bravelle®
Brexafemme®
Breyanzi®
Brineura Brineura® (Medical)
Bronchitol®
Brukinsa™
Buphenyl®
Buphenyl® sodium phenylbutyrate ACSF CHART (Pharmacy)
Buprenorphine®
Buprenorphine SL Tablets (VF Standard)
Buprenorphine® Sublingual Tablets Post Limit
Butorphanol®
Cabenuva®
Cablivi®
Cabometyx®
Calquence®
Capecitabine®
Caprelsa® (Vandetanib) (Pharmacy)
Carbaglu® (Medical)
Carbaglu® (Pharmacy)
Carimune NF®
Carvykti® (Medical)
Cayston®
Cerdelga®(Pharmacy)
Cerezyme® MR (Medical)
Cequa®, Restasis PA with Limit (Pharmacy)
Cetrotide®
Cholbam® (Pharmacy)
Cialis®
Cimzia®
Cimzia® MR (Medical)
Cimzia® (Pharmacy)
Cinqair®
Cinryze® (Medical)
Cinryze® (Pharmacy)
Clindamycin®, Erythromycin Topical Limit-Post Limit
Clotrimazole Troches® Limit
Coagadex®
Cometriq® (Pharmacy)
Compounded Drug Products®
Copaxone
Copiktra®
Corifact®
Corlanor® (Pharmacy)
Corticosteroid Topical Limit-Post Limit
Cosela® (Medical)
Cosentyx®
Cosentyx® (Medical)
Cosentyx® (Pharmacy)
Cotellic® (Pharmacy)
Crysvita®
Cutaquig®
Cuvitru
Cystadane® (Medical)
Cystadane® (Pharmacy)
Cystagon® (Medical)
Cystagon® (Pharmacy)
Cyramza® SGM (Medical)
Cystaran®, Cystadrops® (Pharmacy)
Cytogam®
Dacogen®
Daliresp®
Darzalex®
Darzalex Faspro® (Medical)
Darzalex® (Medical)
Daurismo® (Pharmacy)
Descovy®, Truvada®
Desferal®, deferoxamine®
Desvenlafaxine®
Diabetic Test Strips Medical Necessity
Differin®
Docefrez®
Docetaxel Docetaxel® (Medical)
Doptelet®
Doxepin®
DPP-4 Inhibitors Step Therapy
Dronabinol Post Limit
Duopa™
Dupixent® (Pharmacy)
Dupixent® Enhanced (Pharmacy)
Dupixent® (Exchange)
Dupixent® State Step
Dysport®
Egrifta® (Pharmacy)
Elaprase®
Elelyso® (Medical)
Eligard®
Elidel®
Eloxatin®
Elzonris™
Emflaza®
Empaveli®
Empliciti® (Medical)
Emverm® Post Limit
Enbrel® VF, ACSF (Pharmacy)
Enhertu® (Medical)
Enspryng®
Entresto® (Pharmacy)
Entyvio®
Epidiolex®
Epiduo®, Epiduo Forte
Epinephrine Injectable Limit-Post Limit
Epogen®,Procrit®, Retacrit® (Medical)
Epogen®, Procrit®, Retacrit® ACSF
Erbitux®
Erivedge® (Pharmacy)
Erwinaze®
Esbriet® [pirfenidone] (Pharmacy)
Esperoct®
Euflexxa®
Evenity® (Medical)
Evkeeza® (Medical)
Evrysdi® (Pharmacy)
Exelderm Limit-Post Limit
Exjade® , Jadenu deferasirox ACSF (Pharmacy)
Exelon
Exondys®
Exondys 51®
Extavia®
Extina® Limit-Post Limit
Eylea® MR
Fabior®
Fabrazyme Fabrazyme® (Medical)
Factor IX, Factor IX Complex (Medical)
Factor VIII Agents (Medical)
Farydak® (Pharmacy)
Fasenra® 
Faslodex® [fulvestrant SGM (Medical)
Feiba® NF (Medical)
Fensolvi® (Medical)
Fentanyl Cirtate Oral Tra®
Fentora®
Ferriprox® deferiprone ACSF (Pharmacy)
Fibryga®
Firmagon®
Flebogamma®
Flolan®, Veletri® , and Epoprostenol®
Follistim AQ®
Folotyn®
Forteo®, Teriparatide®, Bonsity® State Step, Marketplace (Pharmacy)
Fortament®
Fotivda®
Freestyle Test Strips® Post Limit
Frova® Post Limit
Fusilev Fusilev® (Medical)
Fuzeon® (Pharmacy)
Galafold®
GamaSTAN®
Gamifant®
Gammagard®
Gammaked®
Gammaplex®
Gamunex®
Ganirelix Acetate®
Gattex®
Gazyva®
Gemcitabine®
Generic Step Therapy - Acne
Genotropin®
Gentamicin Ophthalmic Solution Limit, Post (Pharmacy)
Gentamicin Topical Limit, Post (Pharmacy)
Gilenya®
Gilotrif®
Givlaari®
Glatopa®
Global Post Step Therapy State of Maryland Mandate
Glumetza®
GONAL-F®
GONAL-F RFF®
Granix®
Growth Hormone (Medical)
Growth Hormone (Pharmacy)
Haegarda®
Halaven® (Medical)
Hemlibra® (Medical)
Hepatitis C Generics
Hepatitis C State Step, Generics
Hepatitis C Therapies: Daklinza®, Epclusa®, Harvoni®, Mavyret®, Moderiba®, Olysio®, Pegasys®, Ribasphere RibaPak®, ribavirin®, Sovaldi®, Technivie®, Viekira®, Viekira XR®, Vosevi®, Zepatier®
Hereditary Angioedema
Herceptin Hylecta® MR (Medical)
Herceptin®, Kanjinti®, Ogivri®, Herzuma®, Ontruzant®, Trazimera®
Herceptin®, Trastuzumab®, and biosilimars® MR (Medical)
Hetlioz®
High Risk Medications
Hizentra®
Humatrope®
Humira®
Hyalgan®
Hycamtin® Capsules
HyQvia®
Ibrance® (Medical)
Ibrance® (Pharmacy)
Icatibant®
Iclusig®
Idhifa®
Ilaris®
Ilumya®
Imatinib®
Imbruvica® (Pharmacy)
Imfinzi® (Medical)
Imlygic®
Immune Globulins
Increlex® (Medical)
Increlex® (Pharmacy)
Infertility
Inflectra ® (Medical)
Influenza Post Limit (VF Standard)
Influenza Treatment
Infugem™
Ingrezza®
Inlyta®
Inqovi® (Medical)
Inqovi® (Pharmacy)
Inrebic® (Medical)
Inrebic® (Pharmacy)
Insomnia Agents Post Limit
Intron A®
Intuniv-Kapvay
Iressa®
Ivermectin (Oral) PA with Limit
IVIG
Istodax® (Medical)
Ixempra®
Ixempra® (Medical)
Jadenu®
Jakafi® (Medical)
Jakafi® (Pharmacy)
Jelmyto® (Medical)
Jemperli Jemperli® (Medical)
Jetrea®
Jevtana® 
Jublia® Limit-Post Limit
Juxtapid®, Kynamro® (Pharmacy)
Jynarque® (Pharmacy)
Kadcyla® (Medical)
Kalbitor®
Kalydeco® (Pharmacy)
Kanuma®
Kerendia® (Pharmacy)
Keveyis® (Pharmacy)
Kevzara®
Keytruda Keytruda® (Medical)
Kineret®, VF, ACSF CHART (Medical)
Kineret®, VF, ACSF CHART (Pharmacy)
Kisqali® (Pharmacy)
Kitabis Pak®
Klisyri®
Korlym®
Koselugo® (Pharmacy)
Krystexxa® (Medical)
Kuvan® (Medical)
Kuvan® (Pharmacy)
Kymriah® (Medical)
Kyprolis® (Medical)
Lartruvo®
Lazanda®
Lemtrada® MR (Medcal)
Lenvima® (Pharmacy)
Letairis®
Leukine®
Leuprolide Acetate
Libtayo® (Medical)
Lidocaine Topical Post Limit
Lorbrena®
Lorbrena®(Pharmacy)
Lupron® Hormonal
Lupron® Hormonal MR (Medical)
Lonsurf®
Lovaza®
Lucentis-Byooviz® MR (Medical)
Lumakras®
Lumizyme Lumizyme® (Medical)
Lumoxiti®
Lumoxiti®
Lupkynis®
Lutathera® SGM (Medical)
Luxturna® (Medical)
Lynparza® (Medical)
Lynparza® (Pharmacy)
Lyrica, Gralise, Horizant
Macugen®
Makena®
Margenza® (Medical)
Mekinist® (Pharmacy)
Mektovi®(Pharmacy)
Menopur®
Mepsevii®
Mircera®
Mitoxantrone®
Monovisc®
Mozobil® (Medical)
Mulpleta®
Multiple Sclerosis
Mupirocin Limit-Post Limit
Myalept Myalept® (Medical)
Myalept® (Pharmacy)
Myfembree®
Mylotarg® MR (Medical)
Myobloc® MR (Medical)
Myozyme®
Naglazyme®
Namenda®
Natpara®
Natesto®
Nayzilam®
Nerlynx®
Neulasta®, Fulphila®, Udenyca®, Ziextenzo®, Nyvepria®
Neumega®
Neupogen®,Granix® Nivestym®, Zarxio®,
New to Market Drugs;
Nexavar®
Ninlaro® (Pharmacy)
Northera®
NovoSeven® (Medical)
Noxafil®
Nplate® (Medical)
Nplate®, Promacta®, (Pharmacy)
Nubeqa®
Nucala®
Nuplazid®
Nulibry® (Medical)
Nutropin AQ®
Obizur® (Medical)
Ocaliva®
Ocrevus®
Octagam®
Odomzo® (Pharmacy)
Ofev® (Pharmacy)
Olumiant ®
Omega 3 Fatty Acids
Omnitrope®
Oncaspar®
One Touch® Test Strips
One Touch Verio® Test Strips
Onpattro®
Onsolis®
Opdivo® (Medical)
Opioid Containing Cough and Cold Products Post Limit
Opioids ER - Step Therapy with MME Limit and Post Limit
Opioids IR - Acute Pain Duration Limit with MME Limit and Post Limit
Opioids IR - 3-Day Acute Pain Duration Limit for 19 and Under with MME Limit and Post Limit
Opioids IR - 3-Day APAP-ASA-IBU Combo Products - Acute Pain Duration Limit for 19 and Under
Opsumit®
Opzelura® PA with Limit (Pharmacy)
Oral Pain Meds
Oral CGRP Receptor Antagonists Step Therapy
Orencia® (Pharmacy)
Orencia® (Medical)
Orenitram®
Orfadin®, Nityr nitisinone (Pharmacy)
Orgovyx®
Oriahnn®
Orilissa®
Orkambi® (Pharmacy)
Orladeyo®
Orthovisc®
Osteoarthritis 
Otezla® (Medical)
Otezla® (Pharmacy)
Otrexup®, Rasuvo®
Ovidrel®
Oxaliplatin®
Oxervate®
Oxbryta™
Oxlumo®
Padcev®
Palynziq® ACSF CHART (Medical)
Palynziq® ACSF CHART (Pharmacy)
Pancrelipase®
Panzyga®
Parsabiv®
Peg-Intron®
Pennsaid®
Pepaxto®
Perjeta® (Medical)
Piqray® (Pharmacy)
Phesgo® (Medical)
Plegridy®
Polivy™ (Medical)
Pomalyst® (Pharmacy)
Proton Pump Inhibitors Post Limit
Poteligeo®
Praluent®
Pregnyl®
Privigen®
Procrit® (Medical)
Procysbi® VF, ACSF CHART (Pharmacy)
Proleukin®
Prolia®
Promacta®
Protopic®
Prudoxin®, Zonalon® (Step Therapy)
Pulmozyme® (Pharmacy)
Purixan®
Qinlock®
Radicava® (Medical)
Ranexa®
Rasuvo® State Step (Pharmacy)
Ravicti® ACSF CHART (Medical)
Ravicti® ACSF CHART (Pharmacy)
Rebetol®
RediTrex® State Step (Pharmacy)
Reclast® SGM (Medical)
Regranix®
Remicade® (Medical)
Remodulin®, treprostinil®
Renflexis® (Medical)
Repatha® Enhanced ACSF CHART (Medical)
Repatha® Enhanced ACSF CHART (Pharmacy)
Replax Post Limit®
Repronex®
Relistor® (Pharmacy)
Retacrit® (Medical)
Retevmo®
Retin-A®
Revatio®
Revlimid® (Pharmacy)
Reyvow®
RiaSTAP®
Rinvoq® (Pharmacy)
Rituxan®, Ruxience,®, Truxima®, Riabni® (Medical)
Rituxan Hycela
Rosacea®
Rozlytrek®
Rubraca® (Pharmacy)
Ruconest®
Rybrevant Rybrevant® (Medical)
Rydapt® (Pharmacy)
Ryplazim® (Medical)
Sabril®
Saizen®
Samsca®
Sandostatin Bynfezia Mycapssa octreotide (Medical)
Sandostatin, Bynfezia, Mycapssa octreotide VF (Pharmacy)
Saphnelo (Medical)
Sarclisa®
Scenesse®
Self Injectables
Sensipar® [cinacalcet] (Pharmacy)
Serostim® (Pharmacy)
Sevenfact®
Signifor LAR® (Medical)
Sildenafil®
Siliq® VF, ACSF (Medical)
Siliq® VF, ACSF (Pharmacy)
Simponi® (Medical)
Simponi® (Pharmacy)
Skyrizi (Medical)
Skyrizi (Pharmacy)
Sodium Phenylbutyrate
Solaraze®
Soliris®
Solodyn®
Somatuline Depot® (Medical)
Somavert® ACSF CHART (Medical)
Somavert® ACSF CHART (Pharmacy)
Spinraza®
Sprycel®
Spravato®
Stelara® (Medical)
Stelara® VF, ACSF CHART (Pharmacy)
Stimate® (desmopressin acetate) (Medical)
Stivarga®
Strensiq®
Subsys®
Sucraid®
Supartz®
Supprelin® (Medical)
Sutent®
Sylatron® (Medical)
Sylatron® (Pharmacy)
Sylvant® (Medical)
Symdeko® (Pharmacy)
Synagis®
Synribo®
Synvisc®
Tabrecta®
Tafinlar® VF ACSF (Pharmacy)
Tagrisso®
Takhzyro®
Taltz® VF, ACSF CHART (Medical)
Taltz® VF, ACSF CHART (Pharmacy)
Talzenna® (Pharmacy)
Tamiflu Post Limit®
Tarceva®
Targretin® [bexarotene] (Medical)
Targretin® [bexarotene] (Pharmacy)
Tasigna® State Step
Taxotere®
Tavalisse® sNTM
Tazorac®
Tazverik™(Pharmacy)
TCA Agents (Elderly) Post Limit
Tecartus®
Tecentriq® (Medical)
Tecfidera®
Tegsedi® MR
Temodar® temozolomide (Medical)
Temodar® [temozolomide] (Pharmacy)
Temozolomide®
Tepezza®
Tepmetko®
Terbinafine®
Tetrabenazine®
Tetracycline® Capsules Limit, Post PA (Pharmacy)
Thalomid® (Pharmacy)
Thiola®, EC tiopronin ACSF CHART (Medical)
Thiola®, EC tiopronin ACSF CHART (Pharmacy)
Tibsovo®
Tikosyn®
Tivdak® (Medical)
TOBI®
Tobramycin® (Medical)
Tobramycin® VF, ACSF SGM (Pharmacy)
Torisel®
Tracleer®
Treanda®, Bendeka®, Belrapzo® (Medical)
Trelstar®
Tremfya® VF, ACSF CHART SGM (Medical)
Tremfya® VF, ACSF CHART SGM (Pharmacy)
Tretten®
Tretin-X®
Treximet Post Limit®
Tretinoins (Topical) (Pharmacy)
Triptodur® (Medical)
Trikafta® SGM (Medical)
Trikafta® SGM (Pharmacy)
Trodelvy®
Turalio®
Tukysa ®
Tykerb® SGM (Medical)
Tykerb® SGM (Pharmacy)
Tymlos® (Pharmacy)
Tyrvaya® PA with Limit (Pharmacy)
Tysabri® (Medical)
Tyvaso® (Medical)
Tyvaso® (Pharmacy)
Uplizna®
Uptravi®
Ukoniq®
Uloric®
Ultomiris®
Uplizna®
Valchlor® SGM (Pharmacy)
Valtoco®
Vantas®
Vascepa®
Vectibix®
Velcade® (Medical)
Vemlidy®
Venclexta® SGM (Medical)
Venclexta® SGM (Pharmacy)
Ventavis®
Verzenio® SGM (Medical)
Verzenio® SGM (Pharmacy)
Vfend®
Victrelis®
Vidaza® azacitidin (Medical)
Vidaza® [azacitidine] SGM (Pharmacy)
Vizimpro®
Viltepso®
Vimizim®
Visco-3®
Visudyne®
Vonjo® SGM (Pharmacy)
Vonvendi® (Medical)
Votrient® (Pazopanib)
VPRIV® (Medical)
Vumerity™
Vyepti®
Vyondys™
Vytorin®
Wakix®
Wegovy®
Xartemis® XR MME Limit
Xalkori®
Xeljanz®, Xeljanz® XR VF, ACSF (Pharmacy)
Xeloda® capecitabine (Pharmacy)
Xembify®
Xenazine®
Xeomin®
Xermelo®
Xgeva® (Medical)
Xiaflex®
Xifaxan® 200mg
Xifaxan® 550mg
Xiidra® PA with Limit (Pharmacy)
Xolair®
Xospata® SGM (Medical)
Xospata® SGM (Pharmacy)
Xpovio® State Step, sNTM (Pharmacy)
Xtandi®
Xyrem®
Xywav State Step®
Yervoy® (Medical)
Yescarta® (Medical)
Zaltrap®
Zarxio®
Zavesca®
Zegerid®
Zejula®
Zelboraf® (Pharmacy)
Zepzelca®
Zirabev™
Zoladex® (Medical)
Zolgensma®
Zolinza® SGM (Pharmacy)
Zomacton®
Zometa®, Zoledronic Acid®
Zokinvy®
Zorbtive®
Zulresso Zulresso® (Medical)
Zydelig®
Zyflo®
Zykadia®
Zynlonta®
Zytiga®
Zyvox®