- All FDA-approved medications
(Brand name drugs that require prior authorization and a generic drug equivalent is available or Brand name drugs that require prior authorization without a generic equivalent or any drug with electronic step therapy criteria)
ASTAGRAF XL (tacrolimus extended-release capsules), BEPREVE (bepotastine besilate), BRIVIACT (brivaracetam), CORDRAN LOTION/OINT (flurandrenolide 0.05%), ENVARSUS XR (tacrolimus extended-release tablets), LOCOID (hydrocortisone butyrate lotion 0.1%), risedronate (generic Actonel), PATADAY, PAZEO (olopatadine hcl), TACLONEX SUSPENSION (calcipotriene 0.005% and betamethasone dipropionate 0.064%), WELLBUTRIN XL (bupropion hcl), ZOVIRAX (acyclovir cream 5%), XERESE (acyclovir-hydrocortisone cream 5-1%), ZYCLARA (imiquimod cream 2.5% and 3.75%), ZYFLO (zileuton), ZYFLO CR (zileuton extended-release)
NATL
AND
Drugs requiring electronic step therapy:
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