| Prior Authorization Administrative Guideline |
Admin, Administrative, albendazole, albenza, Prior Authorization |
| Procysbi (cysteamine bitartrate) |
Procysbi (cysteamine bitartrate) |
| Promacta (eltrombopag) |
Promacta (eltrombopag olamine) |
| Proton Pump Inhibitors |
Aciphex (rabeprazole), Aciphex Sprinkle (rabeprazole), Dexilant (dexlansoprazole), Konvomep (omeprazole and sodium bicarbonate), Nexium (esomeprazole), Prevacid (lansoprazole), Prilosec (omeprazole), Protonix (pantoprazole), Zegerid (omeprazole/sodium bicarbonate) |
| Provigil (modafinil), Nuvigil (armodafinil) |
Nuvigil (armodafinil), Provigil (modafinil) |
| Pulmonary Arterial Hypertension Agents |
Adcirca (tadalafil) Tablets, Alyq (tadalafil) Tablets, Tadliq (tadalafil) Oral Suspension, Adempas (riociguat) Tablets, Flolan (epoprostenol sodium) Injection, Letairis (ambrisentan) Tablets, Liqrev (sildenafil) suspension, Opsumit (macitentan) Tablets, Opsynvi (macitentan/ tadalafil) Tablets, Orenitram (treprostinil) Tablets, Remodulin (treprostinil sodium) Injection, Revatio (sildenafil) Injection, Tablets, Oral Suspension, Tracleer (bosentan) Tablets, Tablets for Suspension, Tyvaso (treprostinil) Inhalation Solution, Tyvaso (treprostinil) DPI Inhalation Powder, Uptravi (selexipag) Tablets and Injection, Veletri (epoprostenol) Injection, Ventavis (iloprost) Inhalation Solution, Winrevair (sotatercept-csrk) Injection, Yutrepia (treprostinil) capsule |
| Pulmozyme (dornase alfa inhalation solution) |
Pulmozyme (dornase alpha) Inhalation Solution |
| Pyrukynd (mitapivat) |
Pyrukynd (mitapivat) |
| Qalsody (tofersen) |
Qalsody (tofersen) |
| Qfitlia (fitusiran) |
Qfitlia (fitusiran) |
| Qinlock (ripretinib) |
Qinlock (ripretinib) |
| Quantity Limit General |
Quantity, Quantity limit general |
| Qutenza (capsaicin) |
Qutenza (capsaicin) |
| Radicava (edaravone) |
Radicava (edaravone) injection, Radicava ORS (edaravone) oral suspension |
| Reblozyl (luspatercept-aamt) |
Reblozyl (luspatercept-aamt) |
| Recorlev (levoketoconazole) - PA, NF |
Recorlev (levoketoconazole) |
| Regranex (becaplermin) |
Regranex Gel (becaplermin) |
| Relyvrio (sodium phenylbutyrate and taurursodiol) |
Relyvrio (sodium phenylbutyrate and taurursodiol) |
| Repository Corticotropin Gel Products |
Acthar Gel (repository corticotropin injection), Purified Cortrophin Gel (repository corticotropin injection) |
| Restasis (cyclosporine 0.05%) - PA, NF |
Restasis (cyclosporine 0.05%) ophthalmic emulsion |
HEALTHY LIVING