Arizona Commercial Plans
Prior Authorization Criteria

Coverage of drugs is first determined by the member's pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations.

View Medicare Prior Authorization Criteria

Legend:

natl = Applies to all lines of business in all Health Net regions (AZ, CA, NE, OR)
hnaz = Applies only to Commercial plans (HMO, POS, PPO)

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A

Absorica Abstral Aciphex sprinkle - hnaz
Actemra Actimmune Actiq
Actonel Adcirca Adipex-p
Afinitor Afinitor disperz Aldurazyme
Aloxi Alsuma Amerge
Amnesteem Ampyra Amrix
Amturnide Antidepressant step therapy Anzemet
Apidra Aplenzin Apokyn
Aralast np Aranesp Aranesp albumin free
Aranesp albumin free sure Arcalyst Arimidex - hnaz
Arixtra Aromasin - hnaz Atacand
Atacand hct Atelvia Aubagio
Avastin Avodart Avonex
Axert Azor

B

Belviq Benlysta Berinert
Betaseron Binosto Boniva
Bosulif Botox Bravelle
Breo ellipta Bydureon Byetta

C

Caduet Campral Caverject
Celebrex Centrotide Ceredase
Cerezyme Cesamet Chantix
Cialis - hnaz Cimzia Cinryze
Claravis Clarinex Clarinex-d 12 and 24 hours
Compounded medications Copaxone Copegus
Crinone Cymbalta

D

Dacogen Desoxyn Desvenlafaxine
Dexilant - hnaz Doryx Dysport

E

Edarbi Edarbyclor Edex
Edluar Egrifta Elidel
Eliquis Embeda Enbrel
Endometrin Epogen Exforge
Exforge hct Extavia Eylea

F

Fabrazyme Fanapt Femara - hnaz
Fentanyl citrate oral transmucosal Fentora Firazyr
Flolan Follistim-aq Forfivo xl
Forteo Fosamax plus d Fragmin
Frova Fulyzaq Fuzeon
Fycompa

G

Ganirelex Gattex Genotropin
Gilenya Glassia Gonal-frff
Gralise

H

Human growth hormone Humatrope Humira

I

Iclusig Ilaris Imitrex
Imitrex injection Immunoglobulin conditions not medically necessary Immunoglobulin for aneurysm in kawasaki syndrome
Immunoglobulin for bacterial hiv in children Immunoglobulin for b-cell chronic lymphocytic leuk Immunoglobulin for cidp
Immunoglobulin for dermatomyositis Immunoglobulin for guillain barre syndrome Immunoglobulin for itp
Immunoglobulin for kidney transplant Immunoglobulin for multifocal motor neuropathy Immunoglobulin for multiple myeloma
Immunoglobulin for multiple sclerosis Immunoglobulin for myasthenia gravis Immunoglobulin for neonatal alloimmune thrombocyto
Immunoglobulin for paraneoplastic disorders Immunoglobulin for parvovirus b19 infection Immunoglobulin for pemphigus vulgaris
Immunoglobulin for primary immunodeficiencies Immunoglobulin for stiff person syndrome Incivek
Increlex Infergen Infertility
Inlyta Innohep Intermezzo
Invokana Itraconazole

J

Jalyn Juxtapid

K

Kadcyla Kalbitor Kalydeco
Kineret Korlym Krystexxa
Kuvan Kynamro Kytril

L

Lamictal odt Lamictal xr Lamisil
Lamisil granules Lazanda Leukine
Levitra - hnaz Lidoderm Lipitor - hnaz
Livalo Lotronex Lovenox
Lucentis Lumizyme Lunesta
Luveris Lyrica

M

Macugen Makena Marinol
Maxalt Menopur Micardis
Micardis hct Mozobil Myobloc
Myozyme Mysorian

N

Naglazyme Namenda Nesina
Neulasta Neumega Neupogen
Nexium - hnaz Nicoderm cq Nicorette
Nicotrol inhaler Nicotrol ns Non formulary
Norditropin Novantrone Nplate
Nutropin Nuvigil

O

Omnitrope Omontys Onmel
Onsolis Opana er - hnaz Oracea
Orencia Ovidrel Oxtellar xr
Oxycontin - hnaz

P

Panretin Pegasys Peg-intron
Pomalyst Prevacid - hnaz Pristiq
Prochieve Procrit Pro-fast
Prolastin-c Prolia Promacta
Protopic Provigil

Q

Qsymia Qualaquin

R

Ranexa Ravicti Razadyne
Razadyne er Rebetol Rebif
Reclast Regranex Relistor
Relpax Remicade Remodulin
Renagel - hnaz Renvela - hnaz Repronex
Restasis Revatio Revlimid
Rituxan Rozerem

S

Saizen Sancuso Sandostatin
Sandostatin lar Savella Serostim
Signifor Silenor Simcor
Simponi Sirturo Solodyn
Somavert Sotret Sporanox
Stadol Staxyn - hnaz Stelara
Stendra - hnaz Stivarga Suboxone
Subsys Subutex Sumavel dosepro
Suprenza Symlin Symlin pen
Synagis

T

Taclonex Tarceva Tasigna
Tecfidera Tekamlo Tekturna
Tekturna hct Teveten Teveten hct
Tev-tropin Treximet Tribenzor
Twynsta Tysabri Tyvaso
Tyzeka

U

V

Valcyte Vancocin Ventavis
Viagra - hnaz Victoza Victrelis
Vidaza Viibryd Vimovo
Visudyne Vpriv Vytorin 10 10 mg
Vytorin 10 80 mg

W

X

Xalkori Xeljanz Xenical
Xeomin Xgeva Xiaflex
Xifaxan Xolair Xtandi
Xyrem Xyzal

Y

Z

Zavesca Zegerid - hnaz Zelboraf
Zemaira Zipsor Zofran
Zolinza Zolpimist Zomig
Zorbtive Zuplenz Zyban
Zytiga

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