Prior Authorization/Medical Necessity Determination medicine list

Horizon Blue Cross Blue Shield of New Jersey Pharmacy is committed to providing our members with access to safe and effective medicines. Below you will find a list of medicines requiring Prior Authorization/Medical Necessity Determination. This means that your doctor must give us information to show the use of the medicine meets specific criteria. The criteria follow U.S. Food and Drug Administration (FDA)-approved product labeling and generally accepted treatment guidelines to ensure safe and proper use.

It is important that your doctor submit a request with the information to Horizon Pharmacy to prevent any delay in getting your medicine. If you have any questions, talk with your doctor or call Pharmacy Member Services at 1-800-370-5088.

This list is subject to change and will be updated periodically. The listing below contains the brand name medicines only. The generic versions of these brand name medicines may also be subject to Prior Authorization/Medical Necessity Determination.

You can also look up details about your pharmacy benefits, including if a generic or brand name medicine requires Medical Necessity Determination, by visiting Member Online Services:

Visit HorizonBlue.com/pharmacyservices.
Sign in to Member Online Services with your user name and password.

7T LIDO GEL
ABILIFY
ABILIFY MAINTENA
ABILIFY MYCITE
ABILIFY MYCITE MAINTENANCE KIT
ABILIFY MYCITE STARTER KIT
ABIRATERONE ACETATE
ABSORICA
ABSORICA LD
ACANYA
ACCOLATE
ACCRUFER
ACCUPRIL
ACCURETIC
ACCUTANE
ACIPHEX
ACIPHEX SPRINKLE
ACTEMRA
ACTEMRA ACTPEN
ACTICLATE
ACTIMMUNE
ACTIQ
ACTIVELLA
ACTONEL
ACTOPLUS MET
ACTOS
ACULAR
ACULAR LS
ACYCLOVIR
ACZONE
ADAPALENE
ADAPALENE AND BENZOYL PEROXIDE
ADAPALENE AND BENZOYL PEROXIDE
TOPICAL GEL
ADAPALENE PUMP
ADBRY
ADCIRCA
ADDERALL
ADDERALL XR
ADDYI
ADEMPAS
ADHANSIA XR
ADIPEX-P
ADLARITY
ADLYXIN
ADLYXIN STARTER PACK
ADMELOG
ADMELOG SOLOSTAR
ADZENYS ER
ADZENYS XR-ODT
AFINITOR
AFINITOR DISPERZ
AFREZZA
AGRYLIN
AIMOVIG
AIRDUO DIGIHALER 113/14
AIRDUO DIGIHALER 232/14
AIRDUO DIGIHALER 55/14
AIRDUO RESPICLICK 113/14
AIRDUO RESPICLICK 55/14
AJOVY
AKLIEF
ALA SCALP
ALDACTAZIDE
ALDACTONE
ALDARA
ALECENSA
ALENDRONATE SODIUM
ALINIA
ALKERAN
ALKINDI SPRINKLE
ALLZITAL
ALMOTRIPTAN
ALMOTRIPTAN MALATE
ALOCRIL
ALOGLIPTIN
ALOGLIPTIN/METFORM HCL
ALOGLIPTIN/PIOGLITAZONE
ALORA
ALOSETRON HYDROCHLORIDE
ALPHAGAN P
ALTACE
ALTOPREV
ALTRENO
ALUNBRIG
ALYQ
AMARYL
AMBIEN
AMBIEN CR
AMBRISENTAN
AMCINONIDE
AMERGE
AMICAR
AMITIZA
AMJEVITA
AMNESTEEM
AMPHETAMINE ER
AMPYRA
AMRIX
AMZEEQ
ANADROL-50
ANAFRANIL
ANALPRAM HC
ANALPRAM HC SINGLES
ANAPROX DS
ANASPAZ
ANASTROZOLE
ANCOBON
ANDRODERM
ANDROGEL
ANDROGEL PUMP
ANTARA
ANUSOL-HC
APEXICON E
APIDRA
APIDRA SOLOSTAR
APLENZIN
APOKYN
APOMORPHINE HYDROCHLORIDE
APRISO
APTENSIO XR
ARANESP ALBUMIN FREE
ARAVA
ARAZLO
ARCALYST
ARICEPT
ARIKAYCE
ARIMIDEX
ARISTADA
ARISTADA INITIO
ARIXTRA
ARMONAIR DIGIHALER
AROMASIN
ARTHROTEC 50
ARTHROTEC 75
ASACOL HD
ASPIRIN/OMEPRAZOLE
ASPRUZYO SPRINKLE
ATACAND
ATACAND HCT
ATELVIA
ATIVAN
ATRALIN
AUBAGIO
AUGMENTIN
AUGMENTIN ES-600
AURYXIA
AUSTEDO
AUVELITY
AUVI-Q
AVALIDE
AVAPRO
AVAR LS CLEANSER
AVAR-E LS
AVITA
AVODART
AVONEX
AVONEX PEN
AYGESTIN
AYVAKIT
AZELEX
AZILECT
AZOPT
AZOR
AZSTARYS
AZULFIDINE
AZULFIDINE EN TABS
BACLOFEN
BACTRIM
BACTRIM DS
BAFIERTAM
BALVERSA
BANZEL
BARACLUDE
BECONASE AQ
BELBUCA
BELSOMRA
BENICAR
BENICAR HCT
BENLYSTA
BENZACLIN
BENZACLIN PUMP
BENZAMYCIN
BENZEPRO
BENZONATATE
BENZPHETAMINE HCL
BEPREVE
BESER
BESREMI
BETAMETHASONE DIPROPIONATE
AUGMENTED
BETAMETHASONE VALERATE
BETAPACE
BETAPACE AF
BETASERON
BETHKIS
BEXAROTENE
BEYAZ
BIDIL
BILTRICIDE
BIMATOPROST
BINOSTO
BLEPH-10
BONIVA
BONJESTA
BOSENTAN
BOSULIF
BP CLEANSING WASH
BRAFTOVI
BREXAFEMME
BREZTRI AEROSPHERE
BRISDELLE
BRIVIACT
BRUKINSA
BRYHALI
BUDESONIDE ER
BUDESONIDE/FORMOTEROL
FUMARATE DIHYDRATE
BUMEX
BUPAP
BUPHENYL
BUPRENORPHINE
BUPRIPION HYDROCHOLRIDE ER (XL)
BUTALBITAL/ACETAMINOPHEN
BUTALBITAL/ACETAMINOPHEN/
CAFFEINE
BUTRANS
BYDUREON BCISE
BYDUREON PEN
BYETTA
BYLVAY
BYLVAY (PELLETS)
BYNFEZIA PEN
BYSTOLIC
CABLIVI
CABOMETYX
CADUET
CAFERGOT
CALAN SR
CALCIPOTRIENE
CALCIPOTRIENE/BETAMETHASONE
DIPROPIONATE
CALCITONIN SALMON
CALQUENCE
CAMBIA
CAMZYOS
CAPECITABINE
CAPEX
CAPLYTA
CAPRELSA
CARAC
CARAFATE
CARBAGLU
CARBATROL
CARBINOXAMINE MALEATE
CARDIZEM
CARDIZEM CD
CARDIZEM LA
CARDURA
CARGLUMIC ACID
CARISOPRODOL
CARNITOR
CARNITOR SF
CAROSPIR
CASODEX
CATAPRES-TTS-1
CATAPRES-TTS-2
CATAPRES-TTS-3
CAYSTON
CELEBREX
CELEXA
CELLCEPT
CEPHALEXIN
CEQUA
CERDELGA
CETROTIDE
CHENODAL
CHLORZOXAZONE
CHOLBAM
CHORIONIC GONADOTROPIN
CIALIS
CIBINQO
CILOXAN
CIMETIDINE HCL
CIMETIDINE HYDROCHLORIDE
CIMZIA
CIMZIA STARTER KIT
CINACALCET HYDROCHLORIDE
CIPRO
CIPRODEX
CITALOPRAM HYDROBROMIDE
CLARAVIS
CLARINEX
CLEMASTINE FUMARATE
CLENPIQ
CLEOCIN
CLEOCIN PEDIATRIC GRANULES
CLEOCIN-T
CLIMARA
CLINDAGEL
CLINDAMYCIN PHOSPHATE/
TRETINOIN
CLOBETASOL PROPIONATE
CLOBETASOL PROPIONATE
EMOLLIENT
CLOBEX
CLOCORTOLONE PIVALATE
CLODAN
CLODERM
CLOVIQUE
CLOZAPINE ODT
CLOZARIL
COLAZAL
COLCHICINE
COLCRYS
COLESTID
COLESTID FLAVORED
COMBIGAN
COMBIVIR
COMETRIQ
COMPOUNDED PRESCRIPTION
COSTING $150 OR GREATER
COMTAN
CONCERTA
CONDYLOX
CONJUPRI
CONSENSI
CONTRAVE
CONZIP
COPAXONE
COPIKTRA
CORDRAN
COREG
COREG CR
COREMINO
CORGARD
CORTEF
CORTENEMA
CORTISONE ACETATE
CORVITE 150
COSENTYX
COSENTYX SENSOREADY PEN
COSOPT
COSOPT PF
COTELLIC
COTEMPLA XR-ODT
COZAAR
CRESEMBA
CRESTOR
CRINONE
CUPRIMINE
CUTIVATE
CUVPOSA
CYCLOBENSAPRINE HYDROCHLORIDE
CYCLOBENZAPRINE
HYDROCHLORIDE ER
CYCLOGYL
CYCLOPHOSPHAMIDE
CYCLOSPORINE IN KLARITY
CYMBALTA
CYSTADANE
CYSTADROPS
CYSTARAN
CYTOMEL
CYTOTEC
D.H.E. 45
DALFAMPRIDINE ER
DALIRESP
DANAZOL
DANTRIUM
DARAPRIM
DARTISLA ODT
DAURISMO
DAYPRO
DAYTRANA
DAYVIGO
DDAVP
DEFERASIROX
DEFERIPRONE
DELESTROGEN
DELZICOL
DEMECLOCYLCINE HCL
DEMOCLOCYCLINE HYDROCHLORIDE
DEMSER
DENAVIR
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES
DEPO-TESTOSTERONE
DERMA-SMOOTH /FS BODY
DERMA-SMOOTH /FS SCALP
DERMOTIC
DESCOVY
DESONATE
DESONIDE
DESOWEN
DESOXIMETASONE
DESOXYN
DESRX
DESVENLAFAXINE ER
DETROL
DETROL LA
DEXCHLORPHENIRAMINE MALEATE
DEXCOM G6 RECEIVER
DEXCOM G6 SENSOR
DEXCOM G6 TRANSMITTER
DEXEDRINE
DEXILANT
DHIVY
DIBENZYLINE
DICHLORPHENAMIDE
DICLEGIS
DICLOFENAC
DICLOFENAC EPOLAMINE
DICLOFENAC POTASSIUM
DICLOFENAC SODIUM
DIETHYLPROPION HCL
DIETHYLPROPION HCL ER
DIFFERIN
DIFICID
DIFLORASONE DIACETATE
DIFLUCAN
DIGOXIN
DIHYDROERGOTAMINE MESYLATE
DIOVAN
DIOVAN HCT
DIPROLENE
DIPROLENE AF
DITROPAN XL
DIURIL
DIVIGEL
DOJOLVI
DOPTELET
DORYX
DORYX MPC
DORZOLAMIDE HCL
DORZOLAMIDE HCL/TIMOLOL MALEATE
DOVONEX
DOXEPIN HYDROCHLORIDE
DOXYCYCLINE
DOXYCYCLINE HYCLATE DR
doxycycline monohydrate
DOXYLAMINE SUCCINATE/PYRIDOXINE
HYDROCHLORIDE
DRISDOL
DRIZALMA SPRINKLE
DROXIA
DROXIDOPA
DUAKLIR PRESSAIR
DUETACT
DUEXIS
DUOBRII
DUPIXENT
DURAGESIC
DUREZOL
DYANAVEL XR
DYMISTA
DYRENIUM
E.E.S. GRANULES
EC-NAPROSYN
ECOZA
EDARBI
EDARBYCLOR
EDECRIN
EDLUAR
EFFEXOR XR
EFFIENT
EFUDEX
EGRIFTA SV
ELEPSIA XR
ELETRIPTAN HYDROBROMIDE
ELIDEL
ELIMITE
ELMIRON
ELURYNG
ELYXYB
EMFLAZA
EMGALITY
EMPAVELI
ENABLEX
ENALAPRIL MALEATE
ENBREL
ENBREL MINI
ENBREL SURECLICK
ENDARI
ENDOMETRIN
ENSPRYNG
ENSTILAR
ENTADFI
ENTEREG
ENTOCORT EC
EPANED
EPCLUSA
EPIDIOLEX
EPIDUO
EPIDUO FORTE
EPINEPHRINE
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
EPIVIR
EPIVIR HBV
EPOGEN
EPRONTIA
EPSOLAY
EPZICOM
ERGOMAR
ERGOTAMINE TARTRATE/CAFFEINE
ERIVEDGE
ERLEADA
ERLOTINIB HYDROCHLORIDE
ERMEZA
ERTACZO
ERY
ERYGEL
ERYPED 200
ERYPED 400
ESBRIET
ESOMEPRAZOLE STRONTIUM
ESTRACE
ESTROSTEP FE
ETODOLAC ER
ETONGESTREL/ETHINYL ESTRADIOL
ETOPOSIDE
EUCRISA
EVEKEO
EVEKEO ODT
EVEROLIMUS
EVOCLIN
EVOXAC
EVRYSDI
EXELDERM
EXELON
EXEMESTANE
EXFORGE
EXFORGE HCT
EXJADE
EXKIVITY
EXSERVAN
EXTAVIA
EXTINA
EYSUVIS
EZALLOR SPRINKLE
EZETIMIBE/ATORVASTATIN
EZETIMIBE/ROSUVASTATIN
FABIOR
FAMOTIDINE
FANAPT
FANAPT TITRATION PAK
FARXIGA
FARYDAK
FASENRA PEN
FEBUXOSTAT
FELBATOL
FELDENE
FEMARA
FEMHRT
FENOFIBRATE
FENOFIBRATE MICRONIZED
FENOFIBRIC ACID
FENOGLIDE
FENOPROFEN CALCIUM
FENORTHO
FENTANYL
FENTANYL CITRATE
FENTANYL CITRATE ORAL
TRANSMUCOSAL
FENTORA
FERRIPROX
FERRIPROX TWICE-A-DAY
FETZIMA
FETZIMA TITRATION PACK
FEXMID
FIBRICOR
FINACEA
FINTEPLA
FIORICET
FIRAZYR
FIRDAPSE
FLAGYL
FLECTOR
FLEQSUVY
FLOLIPID
FLOMAX
FLUORIDEX SENSITIVITY RELIEF
FLUORIDEX SENSITIVITY RELIEF/
SLS FREE
FLUORIMAX 5000 SENSITIVE
FLUOROPLEX
FLUOROURACIL
FLUOXETINE DR
FLUOXETINE HYDROCHLORIDE
FLURANDRENOLIDE
FLUTICASONE PROPRIONATE
FLUTICASONE PROPRIONATE/
SALMETEROL
FLUTICASONE PROPRIONATE/
SALMETEROL DISKUS
FLUVASTATIN
FLUVASTATIN SODIUM ER
FML LIQUIFILM
FOCALIN
FOCALIN XR
FOLGARD RX
FOLLISTIM AQ
FORFIVO XL
FORTAMET
FORTEO
FORTESTA
FOSAMAX
FOSRENOL
FOTIVDA
FROVA
FROVATRIPTAN SUCCINATE
FULPHILA
FUROSCIX
FUROSEMIDE
FYCOMPA
FYLNETRA
FYREMADEL
GABITRIL
GALAFOLD
GANIRELIX ACETATE
GASTROCROM
GATTEX
GAVRETO
GELNIQUE
GEMTESA
GENERESS FE
GENOTROPIN
GENOTROPIN MINIQUICK
GEODON
GILENYA
GILOTRIF
GIMOTI
GLATOPA
GLEEVEC
GLUCOSE TEST STRIPS**
GLUCOTROL
GLUCOTROL XL
GLUMETZA
GLYCATE
GLYCOPYRROLATE
GLYDO
GLYNASE
GLYXAMBI
GOCOVRI
GONAL-F
GONAL-F RFF
GONAL-F RFF REDIJECT
GRALISE
GRANIX
GRASTEK
HAEGARDA
HALCINONIDE
HALCION
HALDOL
HALDOL DECANOATE 100
HALDOL DECANOATE 50
HALOBETASOL PROPIONATE
HALOETTE
HALOG
HARVONI
HELIDAC THERAPY
HEMADY
HEPSERA
HETLIOZ
HETLIOZ LQ
HIPREX
HORIZANT
HUMALOG
HUMALOG JUNIOR KWIKPEN
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMATROPE
HUMIRA
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK
HUMIRA PEN
HUMIRA PEN-CD/UC/HS STARTER
HUMIRA PEN-PEDIATRIC UC
STARTER PACK
HUMIRA PEN-PS/UV STARTER
HYCAMTIN
HYDREA
HYDROCODONE BITARTRATE ER
HYDROCORTISONE BUTYRATE
HYDROMORPHONE HCL ER
HYDROMORPHONE
HYDROCHLORIDE ER
HYFTOR
HYSINGLA ER
HYZAAR
IBRANCE
ISBRELA
IBUPROFEN/FAMOTIDINE
ICAR-C PLUS
ICATIBANT ACETATE
ICLUSIG
ICOSAPENT ETHYL
IDHIFA
IMBRUVICA
IMCIVREE
IMIQUIMOD
IMIQUIMOD PUMP
IMITREX
IMITREX STATDOSE REFILL
IMITREX STATDOSE SYSTEM
IMPEKLO
IMPOYZ
IMURAN
IMVEXXY MAINTENANCE PACK
IMVEXXY STARTER PACK
INBRIJA
INCRELEX
INDERAL LA
INDOCIN
INDOMETHACIN
INGREZZA
INLYTA
INQOVI
INREBIC
INSPRA
INSULIN DEGLUDEC
INSULIN DEGLUDEC FLEXTOUCH
INSULIN GLARGINE
INSULIN GLARGINE SOLOSTAR
INSULIN LISPRO
INSULIN LISPRO JUNIOR KWIKPEN
INSULIN LISPRO KWIKPEN
INSULIN LISPRO PROTAMINE/INSULIN
LISPRO KWIKPEN
INTELENCE
INTRAROSA
INTRON A
INTUNIV
INVEGA
INVEGA HAFYERA
INVEGA SUSTENNA
INVEGA TRINZA
INVOKAMET
INVOKAMET XR
INVOKANA
IRESSA
ISOPTO CARPINE
ISORDIL TITRADOSE
ISOSORBIDE DINITRATE
ISOTRETINOIN
ISTALOL
ISTURISA
ITRACONAZOLE
IVERMECTIN
JADENU
JADENU SPRINKLE
JAKAFI
JALYN
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
JATENZO
JAVYGTOR
JAYPIRCA
JENTADUETO
JENTADUETO XR
JORNAY PM
JUBLIA
JUXTAPID
JYNARQUE
KALETRA
KALYDECO
KAPVAY
KARBINAL ER
KATERZIA
KAZANO
KEFLEX
KENALOG
KEPPRA
KEPPRA XR
KERENDIA
KERYDIN
KESIMPTA
KETOCONAZOLE
KETODAN
KETOPROFEN
KETOPROFEN ER
KETOROLAC TROMETHAMINE
KEVEYIS
KEVZARA
KINERET
KISQALI
KISQALI FEMARA 200 DOSE
KISQALI FEMARA 400 DOSE
KISQALI FEMARA 600 DOSE
KITABIS PAK
KLARON
KLISYRI
KLONOPIN
KOMBIGLYZE XR
KORLYM
KOSELUGO
K-PHOS
K-PHOS NEUTRAL
KRAZATI
K-TAB
KUVAN
KYNMOBI
KYZATREX
LACOSAMIDE
LACRISERT
LACTULOSE
LAMICTAL
LAMICTAL CHEWABLE DISPERSIBLE
LAMICTAL ODT
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE
LAMICTAL STARTER/TAKING
CARBAMAZAPINE/NOT TAKING
VALPROATE
LAMICTAL STARTER/TAKING
VALPROATE
LAMICTAL XR
LANOXIN
LANSOPRAZOLE/AMOXICILLIN/
CLARITHROMYCIN
LANTHANUM CARBONATE
LANTUS
LANTUS SOLOSTAR
LAPATINIB DITOSYLATE
LASIX
LASTACAFT
LATANOPROST
LATISSE
LATUDA
LAZANDA
LEDIPASVIR/SOFOSBUVIR
LENALIDOMIDE
LENVIMA 10 MG DAILY DOSE
LENVIMA 12 MG DAILY DOSE
LENVIMA 14 MG DAILY DOSE
LENVIMA 18 MG DAILY DOSE
LENVIMA 20 MG DAILY DOSE
LENVIMA 24 MG DAILY DOSE
LENVIMA 4 MG DAILY DOSE
LENVIMA 8 MG DAILY DOSE
LESCOL XL
LETAIRIS
LETROZOLE
LEUKINE
LEVAMLODIPINE
LEVBID
LEVORPHANOL TARTRATE
LEVOTHYROXINE SODIUM
LEVSIN
LEVSIN/SL
LEXAPRO
LEXETTE
LIALDA
LIBRAX
LICART
LIDOCAINE
LIDOCAINE AND TETRACAINE CREAM
LIDOCAINE HCL
LIDOCAINE HCL JELLY
LIDOCAINE HYDROCHLORIDE
LIDOCAINE PATCH 5%
LIDOCAINE/PRILOCAINE
LIDOCAINE-PRILOCAINE-CREAM BASE
LIDOCAINE/TETRACAINE
LIDODERM
LINZESS
LIPITOR
LIPOFEN
LIVALO
LIVMARLI
LIVTENCITY
LOCOID
LOCOID LIPOCREAM
LODINE
LODOSYN
LOFENA
LOKELMA
LOMAIRA
LOMOTIL
LONHALA MAGNAIR REFILL KIT
LONHALA MAGNAIR STARTER KIT
LONSURF
LOPID
LOPRESSOR
LOPROX
LOPROX SHAMPOO
LORBRENA
LOREEV XR
LORZONE
LOSEASONIQUE
LOTEMAX
LOTENSIN
LOTENSIN HCT
LOTREL
LOTRONEX
LOVAZA
LOVENOX
LUBIPROSTONE
LULICONAZOLE
LUMAKRAS
LUMIGAN
LUNESTA
LUPKYNIS
LUXIQ
LUZU
LYBALVI
LYNPARZA
LYRICA
LYRICA CR
LYSODREN
LYSTEDA
LYTGOBI
LYUMJEV
LYUMJEV KWIKPEN
LYUMJEV TEMPO PEN
LYVISPAH
MACROBID
MACRODANTIN
MALARONE
MAPROTILINE HCL
MARINOL
MATULANE
MAVENCLAD
MAVYRET
MAXALT
MAXALT-MLT
MAXITROL
MAXZIDE
MAXZIDE-25
MAYZENT
MAYZENT STARTER PACK
MECLOFENEMATE SODIUM
MEDROL
MEDROL DOSEPAK
MEKINIST
MEKTOVI
MELOXICAM
MEMANTINE HYDROCHLORIDE
MEMANTINE HYDROCHLORIDE ER
MENOPUR
MEPHYTON
MEPRON
MESTINON
MESTINON TIMESPAN
METAXALONE
METFORMIN HYDROCHLORIDE
METFORMIN HYDROCHLORIDE ER
METHITEST
METHOCARBAMOL
METHOXSALEN
METHYLIN
METHYLPHENIDATE HYDROCHLORIDE ER
METHYLTESTOSTERONE
METROCREAM
METROGEL
METROLOTION
MIACALCIN
MICARDIS
MICARDIS HCT
MICONAZOLE NITRATE/ZINC OXIDE/
WHITE PETROLATUM
MIFEPREX
MIGERGOT
MIGLUSTAT
MIGRANAL
MINASTRIN 24 FE
MINIPRESS
MINIVELLE
MINOCYCLINE HYDROCHOLORIDE ER
MINOLIRA
MIRAPEX
MIRAPEX ER
MIRCERA
MIRCETTE
MITIGARE
MOBIC
MONDOXYNE NL
MORPHINE SULFATE ER
MOTEGRITY
MOTOFEN
MOUNJARO
MOVANTIK
MOVIPREP
MOXEZA
MOXIFLOXACIN HYDROCHLORIDE
MS CONTIN
MULPLETA
MUPIROCIN
MYALEPT
MYAMBUTOL
MYCAPSSA
MYCOBUTIN
MYDAYIS
MYDRIACYL
MYFEMBREE
MYFORTIC
MYORISAN
MYRBETRIQ
MYSOLINE
NAFTIFINE HCL
NAFTIFINE HYDROCHLORIDE
NAFTIN
NALFON
NAMENDA XR
NAMENDA XR TITRATION PAK
NAMZARIC
NAPRELAN
NAPROSYN
NAPROXEN SODIUM
NAPROXEN SODIUM CR
NAPROXEN SODIUM ER
naproxen/esomeprazole
MAGNESIUM
NARDIL
NASCOBAL
NASONEX
NATESTO
NATPARA
NAYZILAM
NEOMYCIN/POLYMYXIN/GRAMICIDIN
NEPHRO-VITE RX
NERLYNX
NESINA
NEULASTA
NEULASTA ONPRO KIT
NEUPOGEN
NEURONTIN
NEXAVAR
NEXIUM
NEXLETOL
NEXLIZET
NIASPAN
NILANDRON
NINLARO
NITISINONE
NITRO-DUR
NITROFURANTOIN
NITROLINGUAL PUMP SPRAY
NITROSTAT
NITYR
NIVESTYM
NIZATIDINE
NOCDURNA
NOLIX
NORDITROPIN FLEXPRO
NORGESIC FORTE
NORITATE
NORLIQVA
NORPRAMIN
NORTHERA
NORVASC
NORVIR
NOURIANZ
NOVAREL
NOXAFIL
NUBEQA
NUCALA
NUCORT
NUCYNTA ER
NUPLAZID
NURTEC
NUTROPIN AQ NUSPIN 10
NUTROPIN AQ NUSPIN 20
NUTROPIN AQ NUSPIN 5
NUVIGIL
NUZYRA
NYMALIZE
NYVEPRIA
OCALIVA
OCTREOTIDE ACETATE
OCUFLOX
ODACTRA
ODOMZO
OFEV
OLUMIANT
OLUX
OLUX-E
OMECLAMOX-PAK
OMEPRAZONE/SODIUM BICARBONATE
OMNARIS
OMNIPOD 5 INTRO KIT (GEN 5)
OMNIPOD 5 G6 PODS (GEN 5)
OMNIPOD CLASSIC PODS (GEN 3)
OMNIPOD DASH INTRO KIT (GEN 4)
OMNIPOD DASH PDM KIT (GEN 4)
OMNIPOD DASH PODS (GEN 4)
OMNITROPE
ONEXTON
ONFI
ONGENTYS
ONGLYZA
ONUREG
ONZETRA XSAIL
OPSUMIT
OPZELURA
ORACEA
ORALAIR
ORALAIR ADULT STARTER PACK
ORALAIR CHILDREN/ADOLESCENTS
STARTER PACK
ORAPRED ODT
ORENCIA
ORENCIA CLICKJECT
ORENITRAM
ORFADIN
ORGOVYX
ORIAHNN
ORILISSA
ORKAMBI
ORLADEYO
ORLISTAT
ORPHENADRINE CITRATE/ASPIRIN/
CAFFEINE
ORPHENGESIC FORTE
ORSERDU
ORTHO MICRONOR
ORTIKOS
OSENI
OSMOLEX ER
OSMOPREP
OSPHENA
OTEZLA
OTREXUP
OVACE PLUS
OVACE PLUS WASH
OVACE WASH
OVIDE
OVIDREL
OXANDROLONE
OXBRYTA
OXERVATE
OXICONAZOLE NITRATE
OXISTAT
OXSORALEN-ULTRA
OXYBUTYNIN CHLORIDE
OXYCODONE HCL ER
OXYCODONE HYDROCHLORIDE ER
OXYCODONE HYDROCHLORIDE/
ACETAMINOPHEN
OXYCONTIN
OXYMORPHONE HYDROCHLORIDE ER
OZEMPIC
OZOBAX
PALFORZIA INITIAL DOSE ESCALATION
PALFORZIA LEVEL 1
PALFORZIA LEVEL 10
PALFORZIA LEVEL 11 (MAINTENANCE)
PALFORZIA LEVEL 11 (TITRATION)
PALFORZIA LEVEL 2
PALFORZIA LEVEL 3
PALFORZIA LEVEL 4
PALFORZIA LEVEL 5
PALFORZIA LEVEL 6
PALFORZIA LEVEL 7
PALFORZIA LEVEL 8
PALFORZIA LEVEL 9
PALYNZIQ
PAMELOR
PANDEL
PARLODEL
PARNATE
PATANASE
PAXIL
PAXIL CR
PEDIAPRED
PEGASYS
PEG-INTRON
PEMAZYRE
PENICILLAMINE
PENNSAID
PENTASA
PEPCID
PERCOCET
PERIDEX
PERSERIS
PEXEVA
PHEBURANE
PHENDIMETRAZINE TARTRATE
PHENDIMETRAZINE TARTRATE ER
PHENELZINE SULFATE
PHENTERMINE HCL
PHENTERMINE HYDROCHLORIDE
PIMECROLIMUS
PIQRAY 200MG DAILY DOSE
PIQRAY 250MG DAILY DOSE
PIQRAY 300MG DAILY DOSE
PIRFENIDONE
PLAQUENIL
PLAVIX
PLEGRIDY
PLEGRIDY STARTER PACK
PLEXION
PLEXION CLEANSER
PLEXION CLEANSING CLOTHS
PLIAGLIS
POLYTRIM
POMALYST
PONVORY
PONVORY 14-DAY STARTER PACK
POSACONAZOLE
POSACONAZOLE DR
PRADAXA
PRALUENT
PRAMOSONE
PRAVACHOL
PRECOSE
PRED FORTE
PREDNICARBATE
PREDNISOLONE ACETATE
PREDNISOLONE ACETATE P-F
PREDNISOLONE SODIUM PHOSPHATE
ODT
PREGABALIN ER
PREGNYL W/DILUENT BENZYL
ALCOHOL/NACL
PREMIUM LIDOCAINE
PREVACID
PREVACID SOLUTAB
PREVIDENT 5000 ENAMEL PROTECT
PREVIDENT 5000 SENSITIVE
PRILOSEC
PRINIVIL
PRISTIQ
PROAIR DIGIHALER
PROAIR HFA
PROCARDIA
PROCARDIA XL
PROCRIT
PROCTOCORT
PROCYSBI
PROGLYCEM
PROLATE
PROMACTA
PROMETRIUM
PROPECIA
PROPRANOLOL HCL
PROSCAR
PROTONIX
PROTOPIC
PROVENTIL HFA
PROVERA
PROVIGIL
PROXIVOL
PROZAC
PRUDOXIN
PULMICORT
PULMICORT FLEXHALER
PYLERA
PYRIDIUM
PYRUKYND
PYRUKYND TAPER PACK
QBRELIS
QBREXA
QDOLO
QELBREE
QINLOCK
QMIIZ ODT
QNASL
QNASL CHILDRENS
QSYMIA
QTERN
QUALAQUIN
QUARTETTE
QUDEXY XR
QUESTRAN
QUESTRAN LIGHT
QUETIAPINE FUMARATE
QUILLICHEW ER
QUILLIVANT XR
QUINAPRIL/HYDROCHLOROTHIAZIDE
QULIPTA
QUVIVIQ
RABEPRAZOLE SODIUM DR SPRINKLE
RADICAVA ORS
RADICAVA ORS STARTER KIT
RAGWITEK
RAMELTEON
RAPAFLO
RAPAMUNE
RASUVO
RAVICTI
RAYALDEE
RAYOS
RAZADYNE ER
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
RECORLEV
REDITREX
REGLAN
REGRANEX
RELAFEN DS
RELEUKO
RELEXXII
RELISTOR
RELPAX
RELTONE
RELYVRIO
REMERON
REMERON SOLTAB
RENAGEL
RENVELA
REPATHA
REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK
RESTASIS
RESTASIS MULTIDOSE
RESTORIL
RETACRIT
RETEVMO
RETIN-A
RETIN-A MICRO
RETIN-A MICRO PUMP
RETROVIR
REVATIO
REVCOVI
REVLIMID
REXULTI
REYVOW
REZLIDHIA
REZUROCK
RHOPRESSA
RILUTEK
RINVOQ
RIOMET
RISPERDAL
RISPERDAL CONSTA
RISPERIDONE ODT
RITALIN
RITALIN LA
ROBAXIN-750
ROBINUL
ROBINUL FORTE
ROCALTROL
ROCKLATAN
ROLVEDON
ROSADAN KIT
ROSZET
ROWASA
ROZEREM
ROZLYTREK
RUBRACA
RUFINAMIDE
RUZURGI
RYALTRIS
RYBELSUS
RYCLORA
RYDAPT
RYTARY
RYTHMOL SR
RYVENT
SABRIL
SAFYRAL
SAIZEN
SAIZEN PREP RECONSTRUCTION KIT
SAJAZIR
SALAGEN
SALEX
SAMSCA
SANCUSO
SANDOSTATIN
SAPHRIS
SAPROPTERIN DIHYDROCHLORIDE
SAXENDA
SCEMBLIX
SEASONIQUE
SECUADO
SEGLENTIS
SEGLUROMET
SELZENTRY
SENSIPAR
SERNIVO
SEROQUEL
SEROQUEL XR
SEROSTIM
SERTRALINE HYDROCHLORIDE
SEVELAMER HYDROCHLORIDE
SEYSARA
SIGNIFOR
SIKLOS
SILDENAFIL
SILDENAFIL CITRATE
SILENOR
SILIQ
SILVADENE
SIMPONI
SINEMET
SINGULAIR
SITAVIG
SKELAXIN
SKLICE
SKYRIZI
SKYRIZI PEN
SKYTROFA
SLYND
SOAANZ
SODIUM OXYBATE
SODIUM PHENYLBUTYRATE
SODIUM SULFACETAMIDE/SULFUR
SODIUM SULFACETAMIDE/SULFUR
CLEANSER IN UREA
SOFOSBUVIR/VELPATASVIR
SOLIQUA 100/33
SOLODYN
SOLOSEC
SOLTAMOX
SOMA
SOMAVERT
SOOLANTRA
SORAFENIB
SORAFENIB TOSYLATE
SORIATANE
SORILUX
SOTYKTU
SOTYLIZE
SOVALDI
SPORANOX
SPORANOX PULSEPAK
SPRIX
SPRYCEL
SSS 10-5
STARLIX
STAVUDINE
STEGLATRO
STEGLUJAN
STELARA
STIMUFEND
STIVARGA
STRATTERA
STRENSIQ
STRIANT
STROMECTOL
SUBSYS
SUCRAID
SUCRALFATE
SULAR
SULCONAZOLE NITRATE
SULFAMYLON
SUMADAN WASH
SUMADAN XLT
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE REFILL
SUMATRIPTAN /NAPROXEN SODIUM
SUMAXIN
SUMAXIN WASH
SUNITINIB MALATE
SUNOSI
SUPRAX
SUPREP BOWEL PREP KIT
SUSTIVA
SUTAB
SUTENT
SYMBYAX
SYMDEKO
SYMPROIC
SYNALAR
SYNDROS
SYNERA
SYNJARDY
SYNJARDY XR
SYPRINE
TABRECTA
TACLONEX
TACROLIMUS
TADALAFIL
TADLIQ
TAFINLAR
TAFLUPROST
TAGRISSO
TAKHZYRO
TALICIA
TALTZ
TALZENNA
TARCEVA
TARGRETIN
TARPEYO
TASCENSO ODT
TASIGNA
TASIMELTEON
TASMAR
TAVABOROLE
TAVALISSE
TAVNEOS
TAYTULLA
TAZAROTENE
TAZORAC
TAZVERIK
TECFIDERA
TECFIDERA STARTER PACK
TEGSEDI
TEKTURNA
TEKTURNA HCT
TEMODAR
TEMOVATE
TEMOZOLOMIDE
TEMPO WELCOME
TENORETIC 100
TENORETIC 50
TENORMIN
TEPMETKO
TERIPARATIDE
TESSALON PERLES
TESTIM
TESTOSTERONE
TESTOSTERONE CYPIONATE
TESTOSTERONE ENANTHATE
TESTOSTERONE PUMP
TESTOSTERONE TOPICAL SOLUTION
TETRABENAZINE
tetracycline hydrochloride
TEXACORT
THALOMID
THIOLA
THYQUIDITY
TIAZAC
TIBSOVO
TIGAN
TIGLUTIK
TIKOSYN
TIMOPTIC
TIMOPTIC OCUDOSE
TIMOPTIC-XE
TINIDAZOLE
TIROSINT
TIROSINT-SOL
TIVORBEX
TIZANIDINE HCL
TIZANIDINE HYDROCHLORIDE
TLANDO
TOBI
TOBI PODHALER
TOBRADEX
TOBRAMYCIN
TOBREX
TOLMETIN SODIUM
TOLSURA
TOLVAPTAN
TOPAMAX
TOPAMAX SPRINKLE
TOPICORT
TOPIRAMATE ER
TOPROL XL
TOSYMRA
TOVET
TOVIAZ
TRACLEER
TRADJENTA
TRAMADOL HCL ER
TRAMADOL HYDROCHLORIDE
TRANXENE T
TRAVATAN Z
TRAVOPROST
TREMFYA
TRETINOIN
TRETINOIN MICROSPHERE
TRETINOIN MICROSPHERE PUMP
TREXALL
TREXIMET
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE ACETONIDE IN
ABSORBASE
TRIANEX
TIBENZOR
TRICOR
TRIDESILON
TRIENTINE HYDROCHLORIDE
TRIFLURIDINE
TRIJARDY XR
TRIKAFTA
TRILEPTAL
TRILIPIX
TRIMETHOPRIM
TRINTELLIX
TRITOCIN
TROKENDI XR
TRUDHESA
TRULANCE
TRULICITY
TRUSELTIQ
TRUSOPT
TRUVADA
TUDORZA PRESSAIR
TUKYSA
TURALIO
TWYNEO
TWYNSTA
TYKERB
TYMLOS
TYRVAYA
TYVASO DPI MAINTENANCE KIT
TYVASO DPI TITRATION KIT
UBRELVY
UCERIS
UDENYCA
ULORIC
ULTRAVATE
UPTRAVI
UPTRAVI TITRATION PACK
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
UROGESIC-BLUE
UROXATRAL
URSO 250
URSO FORTE
URSODIOL
VAGIFEM
VALCYTE
VALIUM
VALSARTAN
VALTOCO
VALTREX
VANCOCIN
VANOS
VASCEPA
VASERETIC
VASOTEC
VELPHORO
VELTASSA
VELTIN
VENCLEXTA
VENCLEXTA STARTING PACK
VENLAFAXINE BESYLATE ER
VERDESO
VEREGEN
VERELAN
VERKAZIA
VERQUVO
VERSACLOZ
VERZENIO
VESICARE
VESICARE LS
VFEND
VIBERZI
VIBRAMYCIN
VICTOZA
VIEKIRA PAK
VIGAMOX
VIIBRYD
VIIBRYD STARTER PACK
VIJOICE
VIMOVO
VIMPAT
VIRAMUNE XR
VIRAZOLE
VIREAD
VISTARIL
VITRAKVI
VIVELLE DOT
VIVJOA
VIVLODEX
VIZIMPRO
VOGELXO
VOGELXO PUMP
VONJO
VOQUEZNA DUAL PAK
VOQUEZNA TRIPLE PAK
VORICONAZOLE
VOSEVI
VOTRIENT
VOXZOGO
VRAYLAR
VTAMA
VTOL LQ
VUITY
VUMERITY
VUSION
VYLEESI
VYNDAMAX
VYNDAQEL
VYTORIN
VYVANSE
VYZULTA
WAKIX
WEGOVY
WELCHOL
WELIREG
WELLBUTRIN SR
WELLBUTRIN XL
WINLEVI
WIXELA INHUB
WYNZORA
XACIATO
XADAGO
XALATAN
XALKORI
XANAX
XANAX XR
XATMEP
XCOPRI
XELJANZ
XELJANZ XR
XELODA
XELPROS
XELSTRYM
XENAZINE
XENICAL
XENLETA
XEPI
XERESE
XERMELO
XHANCE
XIFAXAN
XIGDUO XR
XIIDRA
XIMINO
XOLAIR
XOLEGEL
XOPENEX
XOPENEX CONCENTRATE
XOSPATA
XPOVIO
XPOVIO 100 MG ONCE WEEKLY
XPOVIO 40 MG ONCE WEEKLY
XPOVIO 40 MG TWICE WEEKLY
XPOVIO 60 MG ONCE WEEKLY
XPOVIO 60 MG TWICE WEEKLY
XPOVIO 80 MG ONCE WEEKLY
XPOVIO 80 MG TWICE WEEKLY
XTAMPZA ER
XTANDI
XULTOPHY 100/3.6
XYOSTED
XYREM
XYWAV
YASMIN 28
YAZ
YONSA
YOSPRALA
YUPELRI
ZANAFLEX
ZARXIO
ZAVESCA
ZEGERID
ZEJULA
ZELBORAF
ZELNORM
ZEMBRACE SYMTOUCH
ZEMPLAR
ZENATANE
ZENZEDI
ZEPATIER
ZEPOSIA
ZEPOSIA 7-DAY STARTER PACK
ZEPOSIA STARTER KIT
ZERVIATE
ZESTORETIC
ZESTRIL
ZETIA
ZETONNA
ZIAC
ZIAGEN
ZIANA
ZIEXTENZO
ZILXI
ZIOPTAN
ZIPSOR
ZITHROMAX
ZITHROMAX TRI-PAK
ZITHROMAX Z-PAK
ZOCOR
ZOFRAN
ZOHYDRO ER
ZOKINVY
ZOLINZA
ZOLMITRIPTAN
ZOLMITRIPTAN ODT
ZOLOFT
ZOLPIDEM TARTRATE
ZOLPIMIST
ZOMACTON
ZOMIG
ZOMIG ZMT
ZONALON
ZONEGRAN
ZONISADE
ZORBTIVE
ZORVOLEX
ZORYVE
ZOVIRAX
ZTALMY
ZTLIDO
ZUPLENZ
ZYCLARA
ZYCLARA PUMP
ZYDELIG
ZYKADIA
ZYLOPRIM
ZYMAXID
ZYPITAMAG
ZYPREXA
ZYPREXA RELPREVV
ZYPREXA ZYDIS
ZYTIGA
ZYVOX

(Revised March 1, 2023)

**Lifescan and Ascensia products are preferred. All other test strips are non-preferred and are subjected to prior authorization/medical necessity determination.

This document contains brand name products that are registered marks or registered trademarks of brand manufacturers not affiliated with either Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

This listing of prescription drugs that are subject to Prior Authorization/Medical Necessity review under your prescription coverage is complete as of the date indicated. Please note that new medicines are coming to market with increasing frequency and as a result, this listing is subject to revision on a regular basis.

Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.