Prior Authorization List

The physicians and pharmacists who serve on the Pharmacy & Therapeutics (P&T) Committee are responsible for reviewing all new medications as they come to market. With each agent, they consider whether a medication should be covered under the prescription benefit. In addition, they may recommend quantity limits and prior authorization to ensure appropriate use.

When making a recommendation, the P&T Committee focuses on the medication's overall health benefit as well as the cost. The P&T Committee will consider FDA recommendations, manufacturer package labeling instructions, and published clinical recommendations, such as the Journal of the American Medical Association (JAMA). The P&T has elected to prior authorize the following products:

Drug Name	Therapy Class	Comment
Actiq (fentanyl oral transmucosal)	Narcotic Analgesic
Aranesp	Hematopoietic Agents
Arcalyst	Cryopyrin-associated Periodic Syndromes
Avonex	Multiple Sclerosis
Betaseron	Multiple Sclerosis
Botox	Neuromuscular Blocking Agent
Cesamet	Antiemetics
Clozaril (clozapine)	Schizophrenia
Copaxone	Multiple Sclerosis
Elaprase	Enzyme Replacement Therapy
Emsam	Antidepressants
Epogen	Hematopoietic Agents
Fentora	Narcotic Analgesic
Fuzeon	Anti-Viral
Genotropin	Growth Hormones
Humatrope	Growth Hormones
Increlex	Insulin-like Growth Factors
Infergen	Hepatitis C
Invega	Antipsychotic
Iplex	Insulin-Like Growth Factors
Lamisil	Antifungals
Lamisil (itraconazole)	Antifungals
Letairis	Pulmonary Hypertension
Myozyme	Enzyme Replacement Therapies
Norditropin	Growth Hormones
Noxafil	Antifungals
Nutropin	Growth Hormones
Omnitrope	Growth Hormones
Pegasys	Hepatitis C
PEG-Intron	Hepatitis C
Procrit	Hematopoietic Agents
Protropin	Growth Hormones
Provigil	CNS Stimulant
Raptiva	Antipsoriatic Agents
Rebetron	Hepatitis C
Rebif	Multiple Sclerosis
Reclast	Paget's Disease Agents
Relistor	Opioid-induced Constipation
Revatio	Pulmonary Hypertension
Saizen	Growth hormone
Seroquel 25mg	Antipsychotics
Serostim	Growth Hormones
Soliris	Hematological Agents
Somatuline Depot	Somatostatic Agents
Somavert	Growth Hormone Receptor Antagonist
Sporanox (itraconazole)	Antifungals
Synagis	Antiviral Monoclonal Antibody
Tasigna	Antineoplastic Agents
Tev-Tropin	Growth Hormones
Tracleer	Pulmonary Hypertension
Xolair	Asthma
Xyrem	Anti-cataplexy
Zavesca	Gaucher Disease
Zolinza	Antineoplastic Agents
Zyvox	Antibiotic

As of October 31, 2006, Innoviant’s general prior authorization form was removed from our Web site in favor of customized forms for specific prior authorization programs. To initiate a prior authorization, please contact customer service at 877.559.2955 . We’re available to help 24-hours a day, seven days a week.

A customer service representative can fax a prior authorization form to the prescribing physician. When the physician returns the completed form, a clinical review of the documented information is completed within two business days. The clinical decision is documented in writing to the physician. A copy of the letter provided to the physician is also provided to the member.