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Prescription medications requiring authorization Oregon Health Plan (OHP) Medicaid Some medications have special requirements that could affect your prescription. This list of medication authorizations changes periodically. To learn about a medication's prior effective date, request authorization or see if your medication needs it, please contact our Pharmacy Customer Service team. Questions? Call Pharmacy Customer Service toll-free at 888-474-8539. Brand name Acarbose Generic name Acarbose Medication class Diabetes Restriction type Quantity limit Details Limited to 90 per 30 days Acetaminophen containing opioid products Multiple Pain Management Analgesics Quantity limit Limited to 4g of acetaminophen per day Acetaminoph-CaffDihydrocodein Dhcodeine Bt/Acetaminophn/Caff Pain Management Analgesics Quantity limit Limited to 150 per 30 days For elixir and solution, limited to 990mL per 30 days Acetaminophen-Codeine Acetaminophen With Codeine Pain Management Analgesics Quantity limit For 300mg-15mg And 300mg-30mg, limited to 360 per 30 days For 300mg-60mg, limited to 180 per 30 days Actimmune Interferon Gamma1B,Recomb. Actoplus Met Xr Pioglitazone Hcl/Metformin Diabetes Hcl Step therapy and quantity limit Adefovir Dipivoxil Fluticasone/Salmeterol Fluticasone/Salmeterol Antihemoph.Fviii Plas/Alb Free Antihemoph.Fviii Plas/Alb Free Infectious Disease - Viral Asthma Asthma Prior authorization Quantity limit Quantity limit Limited to 90 per 30 days Clinical criteria Limited to 60 diskus blisters per 30 days Limited to 1 inhaler per 30 days Hematological Disorders Prior authorization Clinical criteria Hematological Disorders Prior authorization Clinical criteria Adefovir Dipivoxil Advair Diskus Advair Hfa Advate Advate H Immunosuppression / Modulation 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Prior authorization Clinical criteria Prior prescription for generic metformin Brand name Advate L Advate M Advate Sh Generic name Antihemoph.Fviii Plas/Alb Free Antihemoph.Fviii Plas/Alb Free Antihemoph.Fviii Plas/Alb Free Medication class Restriction type Details Hematological Disorders Prior authorization Clinical criteria Hematological Disorders Prior authorization Clinical criteria Hematological Disorders Prior authorization Clinical criteria Prior authorization Clinical criteria Prior authorization Clinical criteria Prior authorization Prior authorization Clinical criteria Clinical criteria Immunosuppression / Modulation Urinary Tract - Functional Disorders Neoplastic Disease Neoplastic Disease Alferon N Interferon Alfa-N3 Alfuzosin Hcl Er Alfuzosin Hcl Alimta Alkeran Pemetrexed Disodium Melphalan Amevive Alefacept Dermatology Psoriasis/Eczema Prior authorization Clinical criteria Amicar Aminocaproic Acid Hematological Disorders Prior authorization Clinical criteria Amifostine Aminocaproic Acid Anadrol-50 Android Androxy Anzemet Amifostine Crystalline Aminocaproic Acid Oxymetholone Methyltestosterone Fluoxymesterone Dolasetron Mesylate Neoplastic Disease Hematological Disorders Hormonal Deficiency Hormonal Deficiency Hormonal Deficiency Antiemesis/Antivertigo Prior authorization Prior authorization Prior authorization Prior authorization Prior authorization Prior authorization and Clinical criteria Clinical criteria Clinical criteria Clinical criteria Clinical criteria Clinical criteria Apidra Cartridges and Pens Insulin Glulisine Insulins Prior authorization Clinical criteria Apokyn Apomorphine Hcl Parkinsons Disease Prior authorization Clinical criteria Aralast Alpha-1-Proteinase Inhibitor Miscellaneous Agents Prior authorization Clinical criteria Aralast Np Alpha-1-Proteinase Inhibitor Miscellaneous Agents Prior authorization Clinical criteria Hematological Disorders Prior authorization Clinical criteria Inflammatory Disease Prior authorization Clinical criteria Aranesp Arcalyst Darbepoetin Alfa In Polysorbat Rilonacept 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Generic name Medication class Restriction type Lower Gastrointestinal Quantity limit Disorders - Bowel Inflammat Details Asacol Hd Mesalamine Aspirin-Caffeine- Dihydrocodeine/Aspirin/Caff Pain Management Lymphocyte Immune Immunization Globulin Neurological Disease Teriflunomide Miscellaneous Quantity limit Limited to 360 per 30 days Prior authorization Clinical criteria Auvi-Q Epinephrine Miscellaneous Agents Quantity limit Avastin Avonex Bevacizumab Interferon Beta-1A Neoplastic Disease Neurological Disease - Prior authorization Clinical criteria Prior authorization and Clinical criteria Baraclude Entecavir Infectious Disease - Viral Prior authorization Betaseron Interferon Beta-1B Bethkis Tobramycin Neurological Disease Infectious Disease Miscellaneous Prior authorization Clinical criteria Prior authorization and Clinical criteria quantity limit Bivigam Immune Globulin,Gamma(Igg) Immunization Prior authorization Bosulif Bosutinib Neoplastic Disease Prior authorization and Clinical criteria quantity limit Bunavail Buprenorphine Hcl/Naloxone Hcl Pain Management Analgesics Quantity limit Limited to 60 per 30 days Buphenyl Sodium Phenylbutyrate Prior authorization Clinical criteria Buprenorphine-Naloxone Buprenorphine Hcl/Naloxone Hcl Lower Gastrointestinal Disorders - Other Pain Management Analgesics Quantity limit Limited to 90 per 30 days Buproban Bupropion Hcl Smoking Cessation Prior authorization Clinical criteria Atgam Aubagio 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Limited to 180 per 30 days Prior authorization and Clinical criteria quantity limit Limited To 2 per 30 days Clinical criteria Clinical criteria Brand name Bupropion Hcl Sr Generic name Bupropion Hcl Medication class Behavioral Health - Restriction type Prior authorization Clinical criteria Busulfex Busulfan Neoplastic Disease Prior authorization Clinical criteria Butalb-Acetaminoph-CaffButalb-Caff-AcetaminophCodein Butalbital-AcetaminophenCaffe Butalbit/Acetamin/Caff/Cod Butalbit/Acetamin/Caff/Cod eine Butalb/Acetaminophen/Caff eine Quantity limit Limited to 180 per 30 days Quantity limit Limited to 180 per 30 days Quantity limit Limited to 180 per 30 days Butorphanol Tartrate Butorphanol Tartrate Quantity limit Limited to 2 packages per 30 days Bystolic Nebivolol Hcl Pain Management Pain Management Analgesics Pain Management Analgesics Pain Management Analgesics Cardiovascular Disease Hypertension Quantity limit Limited to 30 per 30 days Cabergoline Cabergoline Endocrine Disorder - Other Quantity limit Limited to 16 per 30 days Capecitabine Capecitabine Neoplastic Disease Prior authorization Clinical criteria Pain Management Analgesics Neoplastic Disease Inflammatory Disease Quantity limit Limited to 990mL per 30 days Caprelsa Celecoxib Acetaminophen With Codeine Vandetanib Celecoxib Ceredase Alglucerase Other Drugs Prior authorization Clinical criteria Cerezyme Imiglucerase Other Drugs Prior authorization Clinical criteria Cesamet Nabilone Antiemesis/Antivertigo Quantity limit Limited to 30 per 30 days Capital W-Codeine Chantix Varenicline Smoking Cessation Details Quantity limit For 100mg, limited to 60 per 30 days Prior authorization and Clinical criteria Quantity limit Quantity limit added to allow a member to receive two 90-day treatments per year. Clinical criteria for any fills after this quantity limit. Cholbam Cholic Acid Hematological Disorders 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Prior authorization Clinical criteria Generic name Brand name Cimzia Certolizumab Pegol Cladribine Cladribine Clonidine Clonidine Clonidine Er Cocet Co-Gesic Combivent Combivent Respimat Medication class Restriction type Details Lower Gastrointestinal Prior authorization Disorders - Bowel Inflammat Clinical criteria Prior authorization Clinical criteria Quantity limit Limited to 4 patches per 28 days Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 0.1mg allow 120 per 30 days Quantity limit Limited to 180 per 30 days Quantity limit Limited to 240 per 30 days Asthma Quantity limit Limited to 2 inhalers per 30 days Asthma Quantity limit Limited to 2 inhalers per 30 days Neoplastic Disease Cardiovascular Disease Hypertension Kapvay Behavioral Health - Other Acetaminophen With Codeine Hydrocodone/Acetaminophe n Ipratropium/Albuterol Sulfate Ipratropium/Albuterol Sulfate Pain Management Analgesics Pain Management Analgesics Clinical criteria Copaxone Glatiramer Acetate Neurological Disease Miscellaneous Prior authorization and For 20mg/mL, limited to 30 syringes per 30 days quantity limit For 40mg/mL, limited to 12 syringes per 28 days Creon Lipase/Protease/Amylase Upper Gastrointestinal Disorders - Digestive 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Prior authorization Clinical criteria Brand name Generic name Medication class Restriction type Details Cresemba Isavuconazonium Sulfate Infectious Disease - Fungal Prior authorization Clinical criteria Cyclophosphamide Cystadane Cyclophosphamide Betaine Prior authorization Prior authorization Clinical criteria Clinical criteria Cystagon Cysteamine Bitartrate Prior authorization Clinical criteria Cytarabine Cytarabine Neoplastic Disease Other Drugs Urinary Tract - Functional Disorders Neoplastic Disease Prior authorization Clinical criteria Ddavp Desmopressin Acetate Endocrine Disorder - Other Prior authorization Clinical criteria Delzicol Mesalamine Lower Gastrointestinal Quantity limit Disorders - Bowel Inflammat Limited to 180 per 30 days Hormonal Deficiency Quantity limit Limited to 1 vial per 30 days Contraception/Oxytocics Quantity limit Limited to 1 injection every 84 days Endocrine Disorder - Other Prior authorization Clinical criteria Behavioral Health - Other Neoplastic Disease Quantity limit Prior authorization Limited to 60 per 30 days Clinical criteria Dextroamphetamine Sulfate Dextroamphetamine Sulfate Behavioral Health - Other Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 5mg, limited to 60 per 30 days 10mg and 15mg, limited to 120 per 30 days Dextroamphetamine Sulfate Dextroamphetamine Sulfate Behavioral Health - Other Er Quantity limit Depo-Provera Depo-Subq Provera 104 Desmopressin Acetate Dexmethylphenidate Hcl Dexrazoxane Medroxyprogesterone Acetate Medroxyprogesterone Acetate Desmopressin (Nonrefrigerated) Dexmethylphenidate Hcl Dexrazoxane Hcl Dextroamphetamine Sulfate Dextroamphetamine Sulfate Behavioral Health - Other Solution 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. For 5mg, limited to 60 per 30 days For 10mg and 15mg, limited to 120 per 30 days Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 5mg/5mL allow 1200mL per 30 days Brand name Generic name Medication class Restriction type Details DextroamphetamineAmphet Er Dextroamphetamine/Amphe Behavioral Health - Other tamine Quantity limit Limited to 60 per 30 days Diazepam Docetaxel Diazepam Docetaxel Quantity limit Prior authorization Limited to 1 kit per 30 days Clinical criteria Donepezil Hcl Odt Donepezil Hcl Prior authorization Clinical criteria Dronabinol Dronabinol Seizure Disorder Neoplastic Disease Autonomic Nervous System Disorders Antiemesis/Antivertigo Prior authorization Dulera Mometasone/Formoterol Asthma Step therapy Elaprase Idursulfase Other Drugs Prior authorization Clinical criteria Prior prescription for Qvar, Pulmicort, Aerobid, Flovent, or Asmanex Clinical criteria Elitek Rasburicase Gout And Related Diseases Prior authorization Clinical criteria Elmiron Pentosan Polysulfate Sodium Quantity limit Limited to 90 per 30 days Eloxatin Elspar Prior authorization Prior authorization Clinical criteria Clinical criteria Neoplastic Disease Prior authorization Clinical criteria Enbrel Enoxaparin Sodium Entecavir Epinephrine Epipen Epipen Jr Epirubicin Hcl Epivir Hbv Oxaliplatin Asparaginase Estramustine Phosphate Sodium Etanercept Enoxaparin Sodium Entecavir Epinephrine Epinephrine Epinephrine Epirubicin Hcl Lamivudine Prior authorization Prior authorization Prior authorization Quantity limit Quantity limit Quantity limit Prior authorization Prior authorization Clinical criteria Clinical criteria Clinical criteria Limited to 2 per 30 days Limited to 2 per 30 days Limited to 2 per 30 days Clinical criteria Clinical criteria Eplerenone Eplerenone Quantity limit Limited to 60 per 30 days Epogen Erbitux Estrasorb Estrogel Epoetin Alfa Cetuximab Estradiol Estradiol Inflammatory Disease Hematological Disorders Infectious Disease - Viral Miscellaneous Agents Miscellaneous Agents Miscellaneous Agents Neoplastic Disease Infectious Disease - Viral Cardiovascular Disease Hypertension Hematological Disorders Neoplastic Disease Hormonal Deficiency Hormonal Deficiency Prior authorization Prior authorization Quantity limit Quantity limit Clinical criteria Clinical criteria Limited to 1 box per 30 days Limited to 1 container per 30 days Emcyt Urinary Tract - Functional Disorders Neoplastic Disease Neoplastic Disease 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Etoposide Exemestane Exjade Generic name Etoposide Exemestane Deferasirox Restriction type Prior authorization Quantity limit Prior authorization Details Clinical criteria Limited to 30 per 30 days Clinical criteria Prior authorization Clinical criteria Agalsidase Beta Medication class Neoplastic Disease Neoplastic Disease Other Drugs Neurological Disease Miscellaneous Other Drugs Extavia Interferon Beta-1B Fabrazyme Prior authorization Clinical criteria Famciclovir Famciclovir Infectious Disease - Viral Quantity limit For 125mg and 250mg, limited to 60 per 30 days For 500mg, limited to 21 per 30 days Fareston Toremifene Citrate Neoplastic Disease Prior authorization Clinical criteria Farydak Faslodex Panobinostat Lactate Fulvestrant Anti-Inhibitor Coagulant Comp. Anti-Inhibitor Coagulant Comp. Neoplastic Disease Neoplastic Disease Prior authorization Prior authorization Clinical criteria Clinical criteria Hematological Disorders Prior authorization Clinical criteria Hematological Disorders Prior authorization Clinical criteria Feiba Nf Feiba Vh Immuno Fentanyl Fentanyl Pain Management Analgesics Quantity limit For 25mcg/Hr, 50mcg/Hr, 75mcg/Hr, and 100mcg/Hr, limited to 15 patches per 30 days For 12mcg/Hr, limited to 10 patches per 30 days Fentanyl Citrate Fentanyl Citrate Fentora Fentanyl Citrate Pain Management Analgesics Pain Management Analgesics Quantity limit Limited to 90 lozenges per 30 days Quantity limit Limited to 90 tablets per 30 days For 30mg and 60mg, limited to 60 per 30 days Fexofenadine Hcl Fludarabine Phosphate Fexofenadine Hcl Fludarabine Phosphate Allergy Neoplastic Disease 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Quantity limit Prior authorization For 180mg, limited to 30 per 30 days Clinical criteria Brand name Fluticasone Propionate Generic name Fluticasone Propionate Medication class Allergy Restriction type Quantity limit Details Limited to 1 bottle per 30 days Focalin Xr Focalin Xr Behavioral Health - Other Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 25mg & 35mg allow 30 per 30-day Forteo Teriparatide Endocrine Disorder - Other Prior authorization Clinical criteria Freestyle Test Strips Freestyle Lite Test Strips Freestyle Freestyle Diabetic Testing Supplies Diabetic Testing Supplies Quantity limit Quantity limit Fulyzaq Crofelemer Lower Gastrointestinal Disorders - Other Prior authorization and quantity limit Limited to 300 test strips per 30 days Limited to 300 test strips per 30 days Clinical criteria Limited to 60 per 30 days Clinical criteria Galantamine Hbr Galantamine Hbr Autonomic Nervous System Disorders Prior authorization and For 8mg, 16mg, and 24mg, limited to 30 per 30 days quantity limit For 4mg and 12mg, limited to 60 per 30 days Gamastan S-D Immune Globulin,Gamma(Igg) Immunization Prior authorization Clinical criteria Genotropin Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Gleevec Imatinib Mesylate Carmustine In Polifeprosan 20 Neoplastic Disease Prior authorization Clinical criteria Neoplastic Disease Prior authorization Clinical criteria Miglitol Diabetes Step therapy and quantity limit Gliadel Glyset Granisetron Hcl Granisetron Hcl Antiemesis/Antivertigo Step therapy and quantity limit Prior prescription for generic metformin Limited to 90 per 30 days Prior prescription for generic ondansetron Limited to 2 tablets per 30 days Limited to 2 vials per 30 days 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Granisol Generic name Granisetron Hcl Medication class Antiemesis/Antivertigo Restriction type Step therapy and quantity limit Details Prior prescription for generic ondansetron Limited to 30 per 30 days H.P. Acthar Corticotropin Endocrine Disorder - Other Prior authorization Clinical criteria Harvoni Ledipasvir/Sofosbuvir Infectious Disease - Viral Prior authorization Clinical criteria Antihemophilic Factor, Hum Hematological Disorders Rec Trastuzumab Neoplastic Disease Altretamine Neoplastic Disease Prior authorization Clinical criteria Prior authorization Prior authorization Clinical criteria Clinical criteria Insulin Lispro Insulins Prior authorization Clinial Criteria Insulin Lispro Insulins Prior authorization Clinical Criteria Insulin Lispro Insulins Prior authorization Clinical criteria Humatrope Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Humira Adalimumab Inflammatory Disease Prior authorization Helixate Fs Herceptin Hexalen Humalog Cartridges and Pens Humalog Mix 50/50 Cartridges and Pens Humalog Mix 75/25 Cartridges and Pens Clinical criteria For 10mg/0.2mL, limited to 2 per 28 days Clinical criteria Humira Pediatric Adalimumab Inflammatory Disease Prior authorization For 3 syringe package size, limited to 3 syringes per 28 days For 6 syringe package size, limited to 6 syringes per 28 days 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Humulin 70/30 Pens Humulin N Pens Hyalgan Ibrance Idarubicin Hcl Ifosfamide Generic name Insulin isophane [NPH] Insulin isophane [NPH] Hyaluronate Sodium Palbociclib Idarubicin Hcl Ifosfamide Restriction type Prior authorization Prior authorization Prior authorization Prior authorization Prior authorization Prior authorization Clinical criteria Clinical criteria Clinical criteria Clinical criteria Clinical criteria Clinical criteria Prior authorization Clinical criteria Etonogestrel Telaprevir Medication class Insulins Insulins Inflammatory Disease Neoplastic Disease Neoplastic Disease Neoplastic Disease Immunosuppression/Modula tion Contraception/Oxytocics Infectious Disease - Viral Imiquimod Imiquimod Implanon Incivek Prior authorization Prior authorization Clinical criteria Clinical criteria Increlex Mecasermin Endocrine Disorder - Other Prior authorization Clinical criteria Infergen Interferon Alfacon-1 Infectious Disease - Viral Prior authorization Clinical criteria Innohep Tinzaparin Sodium,Porcine Hematological Disorders Prior authorization Clinical criteria Intron A Interferon Alfa-2B,Recomb. Prior authorization Clinical criteria Iressa Ixempra Jadenu Prior authorization Prior authorization Prior authorization Clinical criteria Clinical criteria Clinical criteria Diabetes Prior authorization Clinical criteria Diabetes Prior authorization Clinical criteria Januvia Gefitinib Ixabepilone Deferasirox Sitagliptin Phos/Metformin Hcl Sitagliptin Phos/Metformin Hcl Sitagliptin Phosphate Prior authorization Clinical criteria Juvisync Sitagliptin/Simvastatin Diabetes Cardiovascular Disease Miscellaneous Agents Step therapy Prior prescription for generic metformin Kepivance Palifermin Oral/Pharyngeal Disorders Prior authorization Clinical criteria Ketorolac Tromethamine Kineret Ketorolac Tromethamine Anakinra Inflammatory Disease Inflammatory Disease Quantity limit Prior authorization Limited to 20 per 30 days Clinical criteria Janumet Janumet Xr Immunosuppression/Modula tion Neoplastic Disease Neoplastic Disease Other Drugs 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Details Brand name Generic name Medication class Infectious Disease Miscellaneous Kitabis Pak Tobramycin/Nebulizer Kogenate Fs Antihemophilic Factor, Hum Hematological Disorders Rec Restriction type Prior authorization and quantity limit Prior authorization Details Clinical criteria Limited to 280mL per 28 days Clinical criteria Prior prescription for generic metformin Kombiglyze Xr Saxagliptin Hcl/Metformin Hcl Diabetes Quantity limit Prior authorization Clinical criteria Cardiovascular Disease Lipid Irregularity Prior authorization Clinical criteria Insulin Glargine Insulins Prior authorization Clinical criteria Lamivudine Lenvatinib Mesylate Prior authorization Prior authorization Clinical criteria Clinical criteria Prior authorization Clinical criteria Prior authorization Prior authorization Clinical criteria Clinical criteria Prior authorization Clinical criteria Mifepristone Kuvan Sapropterin Dihydrochloride Other Drugs Kynamro Mipomersen Sodium Diabetes Letairis Ambrisentan Leukeran Leukine Chlorambucil Sargramostim Infectious Disease - Viral Neoplastic Disease Cardiovascular Disease Hypertension Neoplastic Disease Hematological Disorders Leuprolide Acetate Leuprolide Acetate Endocrine Disorder - Other Levalbuterol Hcl nebulizer solution For 2.5mg-1000mg, limited to 60 per 30 days For 5mg-1000mg and 5mg-500mg, limited to 30 per 30 days Limited To 120 Per 30 Days Korlym Lantus Cartridges and Pens Lamivudine Hbv Lenvima Step therapy and quantity limit Levalbuterol Hcl Asthma Step therapy and quantity limit Step Therapy requirements added through Ventolin (formulary preferred albuterol inhaler), ProAir, Proventil, albuterol sulfate nebulizer solutions. Limited to 96 vials per 30 days Levemir Pens Insulin detemir Insulins 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Prior authorization Clinical criteria Brand name Levocetirizine Dihydrochloride Liletta Generic name Levocetirizine Dihydrochloride Levonorgestrel Allergy Quantity limit Limtied to 148mL per 30 days Contraception/Oxytocics Prior authorization Clinical criteria Linzess Linaclotide Lower Gastrointestinal Quantity limit Disorders - Bowel Inflammat Limited to 30 per 30 days Neoplastic Disease Prior authorization Clinical criteria Neoplastic Disease Prior authorization Clinical criteria Eye - Miscellaneous Prior authorization Clinical criteria Medication class Restriction type Details Lucentis Doxorubicin Hcl PegLiposomal Doxorubicin Hcl PegLiposomal Ranibizumab Lupron Depot Leuprolide Acetate Endocrine Disorder - Other Prior authorization Clinical criteria Lupron Depot-Ped Leuprolide Acetate Endocrine Disorder - Other Prior authorization Clinical criteria Lyrica Macugen Matulane Maxair Autohaler Medroxyprogesterone Acetate Melphalan Hcl Pregabalin Pegaptanib Sodium Procarbazine Hcl Pirbuterol Acetate Medroxyprogesterone Acetate Melphalan Hcl Seizure Disorder Eye - Miscellaneous Neoplastic Disease Asthma Prior authorization and Prior authorization Prior authorization Quantity limit Clinical criteria Clinical criteria Clinical criteria Limited To 1 Inhaler Per Month Contraception/Oxytocics Quantity limit Limited to 1 injection per 84 days Prior authorization Clinical criteria Memantine Hcl Namenda Prior authorization Clinical criteria Mesna Mesnex Methitest Mesna Mesna Methyltestosterone Neoplastic Disease Autonomic Nervous System Disorders Neoplastic Disease Neoplastic Disease Hormonal Deficiency Prior authorization Prior authorization Prior authorization Clinical criteria Clinical criteria Clinical criteria Methoxsalen Methoxsalen, Rapid Prior authorization Clinical criteria Lipodox Lipodox 50 Dermatology Psoriasis/Eczema 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Methylin Er Generic name Methylphenidate Hcl Medication class Behavioral Health - Other Restriction type Details Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 10mg & 20mg allow 90 per 30 days Methylphenidate Er Methylphenidate Hcl Behavioral Health - Other Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 10mg & 20mg allow 90 per 30-day 10mg/5mL allow 900mL per 30-day Methylphenidate Er Methylphenidate Hcl Behavioral Health - Other Quantity limit For 18mg, 27mg, 36mg, and 54mg, limited to 60 per 30 days Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 5mg/5mL allow 1800mL per 30-day Methylphenidate Solution Methylin Behavioral Health - Other Methylphenidate Sr Methylphenidate Hcl Behavioral Health - Other Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 10mg & 20mg allow 90 per 30 days Methylphenidate Hcl Methylphenidate Hcl Behavioral Health - Other Quantity limit For 10mg/5mL solution, limited to 900mL per 30 Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 10mg, 20mg, 30mg, & 40mg Limited to 60 per 30 days Methylphenidate Hcl Cd Methylphenidate Hcl Behavioral Health - Other 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Generic name Medication class Restriction type Details Methylphenidate La Ritalin La Behavioral Health - Other Quantity limit In alignment with FDA (Food & Drug Administration) dosing recommendations for safety, the following quantity limations will be applied: 20mg & 30mg allow 60 per 30 days, 40mg allow 30 per 30 days Mirena Levonorgestrel Other Drugs Prior authorization Clinical criteria Allergic rhinitis is not a covered condition on the OHP prioritized list of healthcare services. Montelukast Sodium Singular Leukotriene receptor antagonists Step therapy Morphine Sulfate Er Mustargen Morphine Sulfate Mechlorethamine Hcl Pain Management Neoplastic Disease Quantity limit Prior authorization For 90mg and 120mg, limited to 60 per 30 days Clinical criteria Myleran Busulfan Neoplastic Disease Prior authorization Clinical criteria Mylotarg Naglazyme Gemtuzumab Ozogamicin Galsulfase Neoplastic Disease Other Drugs Prior authorization Prior authorization Clinical criteria Clinical criteria Natpara Parathyroid Hormone Endocrine Disorder - Other Prior authorization Clinical criteria Naratriptan Hcl Naratriptan Hcl Pain Management Analgesics Quantity limit Limited to 10 per 30 days Nebupent Pentamidine Isethionate Infectious Disease - Parasitic Prior authorization and quantity limit Neulasta Neumega Neupogen Nevirapine Er Nexavar Nexplanon Pegfilgrastim Oprelvekin Filgrastim Nevirapine Sorafenib Tosylate Etonogestrel Hematological Disorders Hematological Disorders Hematological Disorders Infectious Disease - Viral Neoplastic Disease Contraception/Oxytocics Prior authorization Prior authorization Prior authorization Quantity limit Prior authorization Prior authorization 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Step Therapy requirements added through inhalers indicated for Asthma diagnoses (E.G. Symbicort, Advair, Ventolin, etc…). Clinical criteria Limited to 1 vial per 30 days Clinical criteria Clinical criteria Clinical criteria Limited to 30 per 30 days Clinical criteria Clinical criteria Brand name Nilandron Generic name Nilutamide Medication class Neoplastic Disease Restriction type Prior authorization Clinical criteria Norditropin Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Norditropin Flexpro Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Norditropin Nordiflex Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Novolog Cartridges and Pens Insulin Aspart Insulins Prior authorization Clinical criteria Insulins Prior authorization Clinical criteria Hematological Disorders Prior authorization Clinical criteria Triazole Antifungals Prior authorization Clinical criteria Details Noxafil Insulin Aspart Protamine/ Insulin Aspart Coagulation Factor Viia,Recomb Posaconoazole Nutropin Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Nutropin Aq Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Nutropin Aq Nuspin Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Octreotide Acetate Omeprazole+Syrspend Sf Alka Octreotide Acetate Other Drugs Upper Gastrointestinal Disorders - Ulcer Disease Prior authorization Clinical criteria Quantity limit Limited to 300mL per 30 days Omnitrope Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Novolog Mix 70-30 Pens Novoseven Omeprazole Clinical criteria Ondansetron Hcl Ondansetron Hcl Antiemesis/Antivertigo Prior authorization and For 4mg, limited to 180 per 30 days quantity limit For 8mg, limited to 90 per 30 days 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Opana Er Generic name Oxymorphone Hcl Medication class Pain Management Analgesics Restriction type Step therapy and quantity limit Details Prior prescriptions for generic morphine sulfate or fentanyl patch Limited to 90 per 30 days Opsumit Macitentan Orencia Abatacept/Maltose Orenitram Er Treprostinil Diolamine Orthoclone Okt-3 Muromonab-Cd3 Otezla Apremilast Cardiovascular Disease Hypertension Inflammatory Disease Cardiovascular Disease Hypertension Immunosuppression/Modula tion Prior authorization Clinical criteria Prior authorization Clinical criteria Quantity limit Limited to 90 per 30 days Prior authorization Clinical criteria For Titration Starter Pack, limited to 27 per 14 Days Inflammatory Disease Quantity limit For 30mg, limited to 60 per 30 days Oxaliplatin Oxandrolone Oxaliplatin Oxandrolone Neoplastic Disease Hormonal Deficiency Prior authorization Prior authorization Oxycodone Hcl Oxycodone Hcl Pain Management Analgesics Step therapy and quantity limit Oxycodone Hcl Er Oxycontin Oxymorphone Hcl Er Oxycodone Hcl Oxycodone Hcl Oxymorphone Hcl Pain Management Analgesics Pain Management Analgesics Pain Management Analgesics Step therapy and quantity limit Step therapy and quantity limit Step therapy and quantity limit Clinical criteria Clinical criteria Prior prescription for generic morphine sulfate ER or fentanyl patch Limited to 90 per 30 days Prior prescription for generic morphine sulfate ER or fentanyl patch Limited to 90 per 30 days Prior prescription for generic morphine sulfate ER or fentanyl patch Limited to 90 per 30 days Prior prescription for generic morphine sulfate ER or fentanyl patch Limited to 90 per 30 days 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Generic name Brand name Oxytrol Oxybutynin Panlor Dc Dhcodeine Bt/Acetaminophn/Caff Pantoprazole Sodium Pantoprazole Sodium Paragard T 380-A Copper Medication class Urinary Tract - Functional Disorders Pain Management Analgesics Upper Gastrointestinal Disorders - Ulcer Disease Other Drugs Paricalcitol Paricalcitol Pegasys Pegasys Pegasys Pegintron Pegintron Redipen Peginterferon Alfa-2A Peginterferon Alfa-2A Peginterferon Alfa-2A Peginterferon Alfa-2B Peginterferon Alfa-2B Pentazocine Pentazocine-Acetaminophen Hcl/Acetaminophen Photofrin Porfimer Sodium Pioglitazone Hcl Pioglitazone Hcl Restriction type Quantity limit Limited to 10 per 30 days Quantity limit Limited to 300 per 30 days Quantity limit Limited to 60 per 30 days Prior authorization Clinical criteria Endocrine Disorder - Other Prior authorization Clinical criteria Infectious Disease - Viral Infectious Disease - Viral Infectious Disease - Viral Infectious Disease - Viral Infectious Disease - Viral Pain Management Analgesics Neoplastic Disease Diabetes Prior authorization Prior authorization Prior authorization Prior authorization Prior authorization Clinical criteria Clinical criteria Clinical criteria Clinical criteria Clinical criteria Quantity limit Limited to 180 per 30 days Prior authorization Quantity limit Clinical criteria Limited to 30 per 30 days Step therapy Prior prescription for generic metformin Pioglitazone-Glimepiride Pioglitazone Hcl/Glimepiride Diabetes Pioglitazone-Metformin Pioglitazone Hcl/Metformin Diabetes Hcl Step therapy Pomalidomide Prior authorization and quantity limit Pomalyst Details Neoplastic Disease Prior prescription for generic metformin Limited to 90 per 30 days Clinical criteria Limited to 21 per 28 days Prandimet Repaglinide/Metformin Hcl Diabetes Step therapy Prior Prescription for generic metformin Precision Xtra Test Strips Prezista Freestyle Darunavir Ethanolate Diabetic Testing Supplies Infectious Disease - Viral Quantity limit Quantity limit Limited to 300 test strips per 30 days Limited to 30 per 30 days 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Prialt Generic name Ziconotide Acetate Medication class Pain Management Analgesics Restriction type Details Prior authorization Clinical criteria Quantity limit Limited to 360 per 30 days Prior authorization Clinical criteria Prior authorization Clinical criteria Procrit Oxycodone Hcl/Acetaminophen Epoetin Alfa Procysbi Cysteamine Bitartrate Prolastin Alpha-1-Proteinase Inhibitor Miscellaneous Agents Prior authorization Clinical criteria Prolastin C Alpha-1-Proteinase Inhibitor Miscellaneous Agents Prior authorization Clinical criteria Proleukin Aldesleukin Pulmicort Pulmicort Flexhaler Budesonide Budesonide Primalev Pain Management Analgesics Hematological Disorders Urinary Tract - Functional Disorders Immunosuppression/Modula Prior authorization tion Asthma Quantity limit Asthma Quantity limit Clinical criteria Limited to 60mL per 30 days Limited to 2 inhalers per 30 days Clinical criteria Quillivant Xr Methylphenidate Hcl Behavioral Health - Other For 60mL bottle, limited to 60mL per 30 days Prior authorization and For 150mL bottle, limited to 300mL per 30 days quantity limit For 120mL and 180mL bottle, limited to 360mL per 30 days Qvar Rebetol Beclomethasone Dipropionate Ribavirin Asthma Quantity limit Limited to 3 inhalers per 30 days Infectious Disease - Viral Prior authorization Clinical criteria 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Generic name Relenza Medication class Neurological Disease Interferon Beta-1A/Albumin Miscellaneous Neurological Disease Interferon Beta-1A/Albumin Miscellaneous Antihemophilic Factor, Hum Hematological Disorders Rec Zanamivir Infectious Disease - Viral Remicade Infliximab Rebif Rebif Rebidose Recombinate Remodulin Treprostinil Sodium Repaglinide Revlimid Ribapak Ribasphere Ribasphere Ribavirin Ribavirin Repaglinide Lenalidomide Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin Riluzole Riluzole Ritalin La Rituxan Methylphenidate Hcl Rituximab Rizatriptan Rizatriptan Benzoate Saizen Restriction type Prior authorization Clinical criteria Prior authorization Clinical criteria Prior authorization Clinical criteria Quantity limit Limited to 1 per fill Clinical criteria Lower Gastrointestinal Prior authorization and Disorders - Bowel Inflammat quantity limit Cardiovascular Disease Hypertension Diabetes Neoplastic Disease Infectious Disease - Viral Infectious Disease - Viral Infectious Disease - Viral Infectious Disease - Viral Infectious Disease - Viral Details Limited to 6 vials per 48 days Prior authorization Clinical criteria Step therapy Prior authorization Prior authorization Prior authorization Prior authorization Prior authorization Prior authorization Prior prescription for generic metformin Clinical criteria Clinical criteria Clinical criteria Clinical criteria Clinical criteria Clinical criteria Clinical criteria Neurological Disease Miscellaneous Prior authorization and quantity limit Behavioral Health - Other Neoplastic Disease Pain Management Analgesics Quantity limit Prior authorization Limited to 60 per 30 days Limited to 60 per 30 days Clinical criteria Quantity limit Limited to 12 per 30 days Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Serevent Diskus Salmeterol Xinafoate Asthma Quantity limit Limited to 120 diskus blisters per 30 days Serostim Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Simponi Golimumab Inflammatory Disease Prior authorization and quantity limit 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Clinical criteria Limited to 1mL per 28 days Brand name Generic name Simulect Basiliximab Skyla Soliris Soltamox Somatuline Depot Levonorgestrel Eculizumab Tamoxifen Citrate Lanreotide Acetate Medication class Immunosuppression/Modula tion Other Drugs Hematological Disorders Neoplastic Disease Other Drugs Somavert Pegvisomant Sovaldi Restriction type Details Prior authorization Clinical criteria Prior authorization Prior authorization Step therapy Prior authorization Clinical criteria Clinical criteria Prior prescription for generic metformin Clinical criteria Endocrine Disorder - Other Prior authorization Clinical criteria Sofosbuvir Infectious Disease - Viral Quantity limit Limited to 28 per 28 days Spiriva Spiriva Respimat Sprycel Stelara Tiotropium Bromide Tiotropium Bromide Dasatinib Ustekinumab Asthma Asthma Neoplastic Disease Inflammatory Disease Quantity limit Quantity limit Prior authorization Prior authorization Limtied to 1 inhaler per 30 days Limtied to 1 inhaler per 30 days Clinical criteria Clinical criteria Stimate Desmopressin Acetate Endocrine Disorder - Other Prior authorization Clinical criteria Stivarga Regorafenib Neoplastic Disease Prior authorization and quantity limit Stribild Suboxone Elvitegr/Cobicist/Emtric/Ten Infectious Disease - Viral of Buprenorphine Hcl/Naloxone Hcl Sumatriptan Sumatriptan Sumatriptan Succinate Sumatriptan Succinate Supprelin La Histrelin Ac Sutent Sunitinib Malate Pain Management Analgesics Pain Management Analgesics Pain Management Analgesics Quantity limit Clinical criteria Limited to 84 per 28 days Limited to 30 per 30 days For 12mg-3mg and 4mg-1mg, limited to 30 per 30 days Quantity limit For 12mg-3mg and 8mg-2mg, limited to 90 per 30 days Quantity limit Limited to 6mL (1 package) per 30 days Quantity limit Limited to 10 per 30 days Endocrine Disorder - Other Prior authorization Clinical criteria Neoplastic Disease Prior authorization Clinical criteria 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Medication class Neoplastic Disease Neoplastic Disease Restriction type Prior authorization Prior authorization Asthma Step therapy Symlin Symlinpen 120 Symlinpen 60 Synagis Generic name Peginterferon Alfa-2B Peginterferon Alfa-2B Budesonide/Formoterol Fumarate Pramlintide Acetate Pramlintide Acetate Pramlintide Acetate Palivizumab Diabetes Diabetes Diabetes Infectious Disease - Viral Prior authorization Prior authorization Prior authorization Prior authorization Details Clinical criteria Clinical criteria Previous prescription for Qvar, Pulmicort, Aerobid, Flovent, or Asmanex Clinical criteria Clinical criteria Clinical criteria Clinical criteria Synarel Nafarelin Acetate Endocrine Disorder - Other Prior authorization Clinical criteria Synribo Omacetaxine Mepesuccinate Neoplastic Disease Prior authorization Clinical criteria Tabloid Thioguanine Prior authorization Clinical criteria Brand name Sylatron Sylatron 4-Pack Symbicort Neoplastic Disease For capsules, limited to 10 per fill Tamiflu Oseltamivir Phosphate Infectious Disease - Viral Quantity limit For suspension, limited to 120mL per fill Tanzeum Tarceva Albiglutide Erlotinib Hcl Diabetes Neoplastic Disease Prior authorization Prior authorization Clinical criteria Clinical criteria Targretin Bexarotene Dermatology - Miscellaneous Prior authorization Clinical criteria Tasigna Nilotinib Hcl Neoplastic Disease Prior authorization Tecfidera Dimethyl Fumarate Neurological Disease Miscellaneous Prior authorization and quantity limit Clinical criteria Clinical criteria Temozolomide Temozolomide Neoplastic Disease Prior authorization Limited to 60 per 30 days Clinical criteria Terbinafine Hcl Terbinafine Hcl Infectious Disease - Fungal Quantity limit Limtied to 30 per 30 days 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Generic name Medication class Restriction type Details For 0.04% cream, limited to 45g per prescription Terconazole Terconazole Vaginal Disorders Quantity limit For 0.08% cream, limited to 20g per prescription For 80mg suppositories, limited to 3 suppositories per prescription Testosterone Testosterone Hormonal Deficiency Prior authorization and quantity limit Clinical criteria For 1% gel packet, limited to 30 packets per 30 days Testosterone Cypionate Testosterone Enanthate Testosterone Cypionate Testosterone Enanthate Hormonal Deficiency Hormonal Deficiency Prior authorization Prior authorization Clinical criteria Clinical criteria Testred Methyltestosterone Hormonal Deficiency Prior authorization Clinical criteria Tev-Tropin Somatropin Endocrine Disorder - Other Prior authorization Clinical criteria Thalomid Thalidomide Prior authorization Clinical criteria Thiola Tiopronin Prior authorization Clinical criteria Thiotepa Thiotepa Infectious Disease Miscellaneous Urinary Tract - Functional Disorders Neoplastic Disease Prior authorization Clinical criteria Thrombate Iii Antithrombin Iii (Hum Plas) Hematological Disorders Prior authorization Clinical criteria Thyrogen Thyrotropin Alfa Endocrine Disorder - Other Prior authorization Clinical criteria Tivicay Tobi Podhaler Dolutegravir Sodium Tobramycin Infectious Disease - Viral Infectious Disease - Tobramycin Tobramycin In 0.225% Nacl Infectious Disease Miscellaneous Topotecan Hcl Torisel Topotecan Hcl Temsirolimus Neoplastic Disease Neoplastic Disease Quantity limit Limited to 60 per 30 days Prior authorization and Clinical criteria Clinical criteria Prior authorization and quantity limit Limited to 280mL per 28 days Prior authorization Clinical criteria Prior authorization Clinical criteria 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Generic name Restriction type Tracleer Bosentan Tradjenta Linagliptin Tramadol Hcl Er Tramadol Hcl Tramadol HclAcetaminophen Tranexamic Acid Tramadol Hcl/Acetaminophen Tranexamic Acid Medication class Cardiovascular Disease Hypertension Diabetes Pain Management Analgesics Pain Management Analgesics Hematological Disorders Travoprost Travoprost (Benzalkonium) Eye - Glaucoma Step therapy Trelstar Depot Triptorelin Pamoate Endocrine Disorder - Other Prior authorization Clinical criteria Trelstar La Triptorelin Pamoate Endocrine Disorder - Other Prior authorization Clinical criteria Limited to 300 per 30 days Quantity limit Quantity limit Prior authorization Limited to 1 inhaler per 30 days Limited to 2 per 30 days Clinical criteria Tysabri Natalizumab Prior authorization Clinical criteria Valacyclovir Valacyclovir Hcl Quantity limit Limited to 60 per 30 days Vancomycin Hcl Vancomycin Hcl Pain Management Analgesics Asthma Miscellaneous Agents Neoplastic Disease Neurological Disease Miscellaneous Infectious Disease - Viral Infectious Disease Miscellaneous Quantity limit Tudorza Pressair Twinject Tykerb Dhcodeine Bt/Acetaminophn/Caff Aclidinium Bromide Epinephrine Lapatinib Ditosylate Step therapy Prior prescription for oral metronidazole Vandetanib Vandetanib Trezix Details Prior authorization Clinical criteria Prior authorization Clinical criteria Prior authorization Clinical criteria Quantity limit Limited to 180 per 30 days Quantity limit Limited to 30 per 28 days Prior prescription for generic latanoprost 0.005% eye drops For 100mg, limited to 60 per 30 days Neoplastic Disease Quantity limit For 300mg, limited to 30 per 30 days Vantas Histrelin Ac Endocrine Disorder - Other Prior authorization Clinical criteria Vectibix Velcade Panitumumab Bortezomib Neoplastic Disease Neoplastic Disease Prior authorization Prior authorization Clinical criteria Clinical criteria Veregen Sinecatechins Dermatology - Antiinfective Quantity limit Limited to 1 tube per 30 days Victoza 2-Pak Liraglutide Diabetes Prior authorization Clinical criteria 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Victoza 3-Pak Victrelis Vinblastine Sulfate Vinorelbine Tartrate Viramune Xr Virazole Visudyne Vitrasert Vivaglobin Vivitrol Vyvanse Xarelto Xeljanz Generic name Liraglutide Boceprevir Vinblastine Sulfate Vinorelbine Tartrate Nevirapine Ribavirin Verteporfin Ganciclovir Immune Globulin,Gamma(Igg) Naltrexone Microspheres Medication class Diabetes Infectious Disease - Viral Neoplastic Disease Neoplastic Disease Infectious Disease - Viral Infectious Disease - Viral Eye - Miscellaneous Eye - General Disorders Restriction type Prior authorization Prior authorization Prior authorization Prior authorization Quantity limit Prior authorization Prior authorization Prior authorization Details Clinical criteria Clinical criteria Clinical criteria Clinical criteria Limited to 30 per 30 days Clinical criteria Clinical criteria Clinical criteria Immunization Prior authorization Clinical criteria Behavioral Health - Other Prior authorization Lisdexamfetamine Dimesylate Behavioral Health - Other Prior authorization and quantity limit Clinical criteria Clinical criteria Rivaroxaban Hematological Disorders Tofacitinib Citrate Inflammatory Disease Quantity limit Prior authorization and quantity limit Xifaxan Xolair Rifaximin Omalizumab Anti-infective Agents Asthma Prior authorization Prior authorization Xopenex Hfa Levalbuterol Tartrate Asthma Step therapy and quantity limit Xtandi Xyrem Enzalutamide Sodium Oxybate Neoplastic Disease Behavioral Health - Other 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Prior authorization and quantity limit Prior authorization Limited to 30 per 30 days For 10mg and 15mg, limited to 60 per 30 days For 20mg, limited to 30 per 30 days For 15mg-20mg Starter Pack, limited to 51 per 30 days Clinical criteria Limited to 60 per 30 days Clinical criteria Clinical criteria Step Therapy requirements added through Ventolin (formulary preferred albuterol inhaler), ProAir, or Proventil. Limited to 3 inhalers per 30 days Clinical criteria Limited to 120 per 30 days Clinical criteria Zaleplon Zanosar Zavesca Generic name Zaleplon Streptozocin Miglustat Restriction type Quantity limit Prior authorization Prior authorization Details Limited to 60 per 30 days Clinical criteria Clinical criteria Zemaira Alpha-1-Proteinase Inhibitor Miscellaneous Agents Prior authorization Clinical criteria Zerlor Dhcodeine Bt/Acetaminophn/Caff Pain Management Analgesics Quantity limit Limited to 150 per 30 days Zoladex Goserelin Acetate Endocrine Disorder - Other Prior authorization Clinical criteria Quantity limit Limited to 6 per 30 days Quantity limit Step Therapy Prior authorization Prior authorization Limited to 6 per 30 days Prior prescription for generic zolpidem Clinical criteria Clinical criteria Quantity limit Limited to 300 per 30 days Prior authorization Clinical criteria Brand name Zolmitriptan Zolmitriptan Odt Zolpidem Tartrate Er Zontivity Zorbtive Zydone Zykadia Medication class Behavioral Health - Other Neoplastic Disease Other Drugs Pain Management Analgesics Zolmitriptan Pain Management Zolpidem Tartrate Behavioral Health - Other Vorapaxar Sulfate Hematological Disorders Somatropin Endocrine Disorder - Other Hydrocodone/Acetaminophe Pain Management n Analgesics Ceritinib Neoplastic Disease Zolmitriptan 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Brand name Generic name Medication class 2016.3 (7/1/2016). For prior effective dates, please contact Moda Health. Restriction type Details
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