Medications Requiring Prior Authorization
IU Health Pharmacy Benefits Management
1776 N Meridian Street, Indianapolis, IN 46202
Phone: 317-963-3347 877-769-0191
Prior Auth Fax: 866-429-8920
**Medications on this list require prior authorization prior to filling at the pharmacy.
Please complete the appropriate form prior to directing the patient to the pharmacy.
Brand
Generic
Analgesic
ziconotide
Analgesics, Opioid
Avinza
morphine sulfate
Buprenorphine
buprenorphine
Oxycontin
oxycodone
Local Anesthetic
Lidoderm
lidocaine
Antibacterials
Cubicin
daptomycin
Invanz
ertapenem
Primaxin
cilastatin;imipenem
Synercid
dalfopristin;quinupristin
Tobi
tobramycin
Zyvox (tablets excluded) linezolid
Anticoagulants
Prialt
Authorization required for therapy durations greater than 10 days
Arixtra
Fragmin
Innohep
Lovenox
Pradaxa
Xarelto
fondaparinux
dalteparin
tinzaparin
enoxaparin
dabigatran
rivaroxaban
Antidote
Exjade
deferasirox
Antiemetics
Anzemet
dolasetron
Kytril (excludes oral)
granisetron
Zofran (excludes oral)
ondansetron
Antifungals
Cancidas
caspofungin
Eraxis
anidulafungin
Mycamine
micafungin
Vfend
voriconazole
Antipsychotics
Invega Sustenna
paliperidone
Rispe
Risperdal Consta
risperidone
Antineoplastics
Abraxane
paclitaxel
Alimta
pemetrexed
Arranon
nelarabine
Avastin
bevicizumab
Bleomycin
bleomycin
Busulfex
busulfan
Camptosar
irinotecan
Carboplatin
carboplatin
Ceenu
lomustine
Cladribine
cladribine
Clolar
clofarabine
Cosmegen
dactinomycin
Cytarabine
cytarabine
Dacogen
decitabine
Doxil
doxorubicin liposome
Ellence
epirubicin
Eloxatin
oxaliplatin
Erbitux
cetuximab
Ethyol
amifostine
Fareston
toremifene
Faslodex
fulvestrant
Fludara
fludarabine
Fludarabine
fludarabine
Gemzar
gemcitabine
Gleevec
imatinib
Herceptin
trastuzumab
Hycamtin
topotecan
Idamycin PFS
idarubicin
Idarubicin
idarubicin
Ifosfamide
ifosfamide
Ifosfamide/Mesna
ifosfamide;mesna
Iressa
Leustatin
Mesnex
Mylotarg
Novantrone
Octreotide
Oncaspar
Paclitaxel
Photofrin
Revlimid
Rituxan
Sprycel
Sutent
Tarceva
Taxotere
Temodar
Thalomid
Torisel
Tretinoin capsules
Trisenox
Tykerb
Vectibix
Velcade
Vidaza
Vinorelbine
Votrient
Vumon
Xeloda
Zolinza
Mepron
Pentam 300
gefitinib
cladribine
mesna
gemtuzumab ozogamicin
mitoxantrone
octreotide
pegaspargase
paclitaxel
porfimer
lenalidomide
rituximab
dasatinib
sunitinib
erlotinib
docetaxel
temozolomide
thalidomide
temsirolimus
tretinoin
arsenic trioxide
lapatinib
panitumumab
bortezomib
azacitidine
vinorelbine
pazopanib
teniposide
capecitabine
vorinostat
Antiparasitic
atovaquone
pentamidine
Updated 1/30/2012, subjectt to change based on continual review process
Antivirals
Copegus
ribavirin
Fuzeon
enfuviratide
Hepsera
adefovir dipivoxil
Rebetol
ribavirin
Ribapak
ribavirin
Ribasphere
ribavirin
Ribavirin
ribavirin
Virazole
ribavirin
Focarnet sodium
foscarnet
Blood Formation Products
Aranesp
darbepoetin alfa
Epogen
epoetin alfa
Leukine
sargramostim
Neulasta
pegfilgrastim
Neumega
oprelvekin
Neupogen
filgrastim
Procrit
epoetin alfa
Blood Glucose Regulator
Byetta
exenatide
Dermatologic Agent
Stelara
ustekinumab
Diuretic
Diamox
acetazolamide
Enzyme Replacement/Modifiers
Adagen
pegademase bovine
Aldurazyme
laronidase
Buphenyl
sodium phenylbutyrate
Ceredase
alglucerase
Cerezyme
imiglucerase
Elaprase
idursulfase
Fabrazyme
agalsidase beta
Kuvan
sapropterin
Myozyme
alglucosidase alfa
Orfadin
nitisinone
Glucocorticoids
Entocort EC
budesonide
Solu-Cortef
hydrocortisone
Solu-Medrol
methylprednisolone
Hormonal Modifiers
Acthar HP
corticotropin
Eligard
leuprolide
Genotropin
somatropin
Humatrope
somatropin
Increlex
mecasermin
Leuprolide acetate
leuprolide
Lupron Depot
leuprolide
Lupron Depot- PED
leuprolide
Norditropin
somatropin
Nutropin
somatropin
Nutropin AQ
somatropin
Omnitrope
somatropin
Plenaxis
abarelix
Saizen
somatropin
Sandostatin
octreotide
Serostim
somatropin
Somavert
pegvisomant
Supprelin LA
histrelin
Synarel
nafarelin
Trelstar LA
triptorelin
Zoladex
goserelin
Zorbtive
somatropin
Immune Suppressants
CellCept (excludes oral)
mycophenolate mofetil
Cimzia
certolizumab pegol
Enbrel
etanercept
Humira
adalimumab
Orencia
abatacept
Orthoclone OKT3
muromonab CD3
Remicade
infliximab
Simponi
golimumab
Simulect
basilimab
Immunizing Agents
Atgam
anti-thymocyte globulin
Carimune
immune globulin
Flebogamma
immune globulin
Gamastan S/D
immune globulin
Gammagard
immune globulin
Gamunex
immune globulin
Octagam
immune globulin
Thymoglobulin
anti-thymocyte globulin
Vivaglobin
immune globulin
Immunomodulators
Actimmune
interferon gamma-1b
Alferon N
interferon alfa-n3
Avonex
Interferon beta-1a
Betaseron
Interferon beta-1b
Copaxone
glatiramer
Infergen
interferon alfacon-1
Intron-A
interferon alfa-2b
Kineret
anakinra
Pegasys
peginterferon alfa-2a
Peg-Intron
peginterferon alfa-2b
Rebif
interferon beta-1a
Synagis
palivizumab
Tysabri
natalizumab
Metabolic Bone Disease Agents
Aredia
pamidronate
Boniva (excludes oral)
ibandronate
Forteo
teriparatide
Zometa
zoledronic acid
Miscellaneous
Botox
onabotulinumtoxin a
Cymbalta
duloxetine
Myobloc
rimabotulinumtoxin b
Nuvigil
armodafinil
Provigil
modafinil
Oral/Dental Agent
Kepivance
palifermin
Pulmonary Antihypertensive Agents
Letairis
ambrisentan
Remodulin
treprostinil
Revatio
sildenafil
Tracleer
bosentan
Ventavis
iloprost
Naglazyme
galsulfase
Respiratory Agents
Aralast NP
proteinase
Prolastin
proteinase inhibitor
Pulmozyme
dornase alfa
Xolair
omalizumab
Zemaira
proteinase inhibitor
Toxicologic Agents
Revia
natrexone
Suboxone
buprenorphine;naloxone
Vivitrol
naltrexone
Subutex
buprenorphine
Vaccines
Theracys
BCG vaccine
Tice BCG
BCG vaccine
Updated 1/30/2012, subject to change based on continual review process