Endocrine
Gonadotropin-Releasing Hormone (GnRH) | ||
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Supprelin® LA (Histrelin), Synarel® (Nafarelin), and Triptodur® (Triptorelin) Approval Criteria:
elagolix (Orilissa™) Approval Criteria:
leuprolide acetate for Depot Suspension and Norethindrone Acetate Tablets (Lupaneta Pack™) Approval Criteria:
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Tier 1 | Tier 2 | Tier 3 |
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Preferred |
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Tier 1 |
Tier 2 |
Tier 3 |
Special PA |
Biaguanides
Sulfonylureas
Alpha-Glucosidase Inhibitors
Glinides
Thiazolidinediones
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DDP-4 Inhibitors
SGLT2 inhibitor
Glinides
GLP-1 Agonists
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DDP-4 Inhibitors
Thiazolidinediones
Alpha-Glucosidase Inhibitors
SGLT2 inhibitor
Dopamine Agonist
SGLT-2/DPP-4 Inhibitor
GLP-1 Agonists
GLP-1 Agonists/Insulin
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Biaguanides
Amylinomimetic
DDP-4 Inhibitors
SGLT2 inhibitor
GLP-1 Agonists
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* Authorization of Jentadueto® XR will require tier trials be met and a reason why the member cannot take the immediate-release formulation.
Insulin Products | ||
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Admelog® (Insulin Lispro) Approval Criteria:
Afrezza® (Insulin Human) Inhalation Powder Approval Criteria:
Fiasp® (Insulin Aspart) Approval Criteria:
Humulin® R U-500 Vials (Insulin Human 500 Units/mL) Approval Criteria:
Humalog® KwikPen® U-200 (Insulin Lispro 200 Units/mL) Approval Criteria:
Toujeo® (Insulin Glargine) Approval Criteria:
Tresiba® (Insulin Degludec) Approval Criteria:
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pregabalin (Diabetic Neuropathy Diagnosis) | ||
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pregabalin (Lyrica®) Approval Criteria (Diabetic Neuropathy Diagnosis):
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Tier 1 |
Tier 2 |
Special PA |
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progesterone vaginal gel/inserts | ||
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progesterone vaginal gel (Crinone®) Approval Criteria:
progesterone vaginal insert (Endometrin®) Approval Criteria:
Prior Authorization form |
estradiol gel | ||
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estradiol gel 0.06% (Elestrin®) Approval Criteria:
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hydroxyprogesterone caproate (Generic Delalutin®) | ||
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PA Criteria:
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Vitamin D Analogs | ||
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calcifediol er capsules (Rayaldee®) Approval Criteria:
etelcalcetide injection (Parsabiv™) Approval Criteria:
paricalcitol capsules (Zemplar®) Approval Criteria:
doxercalciferol capsules (Hectorol®) Approval Criteria:
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If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.