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PART D PHARMACY PRIOR AUTHORIZATION
The following drugs DO NOT require prior authorization under the Part D benefit:
Accuneb Cellcept Fosamax 40mg Myobloc Rebetol Testoderm
Actimmune Cerezyme Inj Foscarnet Inj Nebupent Rebetron Testred
Actiq Ciprofloxacin Inj Gabitril Neoral Rebif Thalomid
Actonel 30mg Cis Platin Inj Gammar Nicotine Patch Regranex Tobi
Acyclovir inj Cladribine Inj Gammimune N Nicotrol Relenza Tracleer
Adderall/Adderrall
XR Cognex Gangiclovir Inj
Nitroglycerin
Inj Remicaid Triseonx Inj
Alupent Nebulizer Concerta Genotropin Norditropin Reminyl Ultracet
Amevive Copaxone Gleevec Ofloxacin Inj Restatis Ultram
Amphotericin B Inj Copegus Halotestin Orthoclone Retin A Venoglobulin
Anabolic Steroids Delatestryl Hepsera Oxandrin Ribavirin Vfend
Anadrol Depo Testosterone Humatrope Oxycodone SR Ritalin/SR/LA Vfend Inj
Androgel Desoxyn Humira Panretin Roferon Vidaza
Anzemet Dexedrine Infergen Pegasys Saizen Vitraset
Apokyn Diflucan 150mg Tab Intron A Peg-Intron Sandimmune Winstrol
Arava Dobutamine Inj Iressa Penlac Sandoglobulin Xifaxin
Atrovent Amp Dopamine Inj Kepivance Pentamidine Inj Sensipar Xolair
Avastin Doxycycline Inj Kineret Prograf Skelid 200mg Xoponex
Avelox Inj DuoNeb Kytril Prolastine Inj Somavert Zavesca
Avonex Elidel Lotrenox Protonix Inj Stadol NS Zelnorm
Balcofen Inj Emend Lunesta Protopic Straterra Zenapax
BCG Vaccine Enbrel Metadate CD Protropin Symlin Zithromax Inj
Betaseron Erbitux
Methotrexate
(MTX)
Provigil Tamiflu Zofran
Botox Farbazyme Inj Methylin ER Pulmicort Resp. Tarceva Zyvox
Brethine Amp Fludarabine Inj Metronidazole Inj Pulmozyme Targretin Gel
Byetta Focalin Mucomyst Rapamune Tazorac Cream
Camptosar Inj Forteo Myfortic Raptiva Testim
