DK - Dakotacare

Drugs Requiring Preauthorization under Pharmacy Benefits
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Actimmune®
Adcirca™
Adempas®
Ampyra™
Antifungal Nasal Compounds
Aubagio®
Bydureon®
Byetta™
Carbaglu®
Cimzia®
Compounded Rx ≥$350
Copaxone®
Crinone®
Eliquis®
Enbrel®
Exjade®
Ferriprox®
Firazyr®
Forteo®
Gattex®
Gilenya®
Growth Hormones:
-Genotropin®
-Saizen®
-Humatrope®
-Serostim®
-Increlex™
-Somavert®
-Norditropin® -Tev-Tropin®
-Nutropin AQ® -Zorbtive®
-Omnitrope™
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Hizentra®
Humira®
Incivek®
Interferons:
-Avonex®
-Pegasys®
-Betaseron® -PegIntron™
-Extavia®
-Rebif®
-Intron® A
Juxtapid®
Kalydeco®
Kineret
Korlym®
Kuvan™
Kynamro®
Letairis™
modafinil (Provigil ®)
Myalept®
Northera®
Noxafil®
Nuedexta
Nuvigil®
octreotide (Sandostatin®)
Olysio®
Opsumit®
Orencia SQ®
Orenitram®
Otezla®
Pradaxa®
Progesterone, age<40
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Promacta®
Ravicti®
Relistor®
Samsca™
sildenafil (Revatio®)
Simponi™
Sovaldi®
Stelara™
Sucraid®
Symlin®
Tanzeum®
Tecfidera®
Thalomid®
Tracleer®
Tyvaso®
Ventavis®
Victoza®
Victrelis®
Xarelto®
Weight Loss Medications
Xeljanz®
Xenazine
Zavesca®
Zyvox®
Zytiga®
Drugs Requiring Preauthorization under Medical Benefits
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Actemra®
Alferon® N
Arcalyst™
Benlysta®
Berinert®
Botox®
Cerezyme®
Cinryze™
Dysport®
Elelyso®
Entyvio®
epoprostenol (Flolan®, Veletri®)
Ilaris®
- Italics indicates a specialty medication
MM\DKC Drug Preauth List (09-25-14) (DKC AP, HX, I, PPPortMD)
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Immune Globulins®
Kalbitor®
Krystexxa™
Myobloc®
Naglazyme®
Orencia®
Prolia™
Remicade®
Remodulin®
Revatio™ inj.
Rituxan®
Sandostatin® LA
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Soliris™
Somatuline®
Supprelin LA
Synagis®
Tysabri®
Vimizim®
Vivitrol™
Vpriv™
Xeomin®
Xgeva™
Xiaflex®
Xolair®

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