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Prior Authorization Drug List


Horizon Pharmacy is committed to providing our members with access to safe and effective medicines. This list of medicines require 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 sign in to look up details about your pharmacy benefits, including if a generic or brand name medicine requires Medical Necessity Determination.

7T LIDO GEL
ABILIFY
ABILIFY MAINTENA
ABILIFY MYCITE
ABIRATERONE ACETATE
ABSORICA
ABSORICA LD
ABSTRAL
ACANYA
ACCOLATE
ACCUPRIL
ACCURETIC
ACCUTANE
ACIPHEX
ACIPHEX SPRINKLE
ACTEMRA
ACTEMRA ACTPEN
ACTICLATE
ACTIGALL
ACTIMMUNE
ACTIQ
ACTIVELLA
ACTONEL
ACTOPLUS MET
ACTOS
ACULAR
ACULAR LS
ACZONE
ADALAT CC
ADAPALENE
ADAPALENE AND BENZOYL PEROXIDE
ADAPALENE PUMP
ADCIRCA
ADDERALL
ADDERALL XR
ADDYI
ADEMPAS
ADHANSIA XR
ADIPEX-P
ADLYXIN
ADLYXIN STARTER PACK
ADMELOG
ADMELOG SOLOSTAR
ADZENYS XR
ADZENYS XR-ODT
AFINITOR
AFINITOR DISPERZ
AFREZZA
AGGRENOX
AGRYLIN
AIMOVIG
AIRDUO DIGIHALER
AIRDUO RESPICLICK
AJOVY
AKLIEF
AKTIPAK
ALA SCALP
ALDACTAZIDE
ALDACTONE
ALDARA
ALECENSA
ALENDRONATE SODIUM
ALINIA
ALKERAN
ALLZITAL
ALMOTRIPTAN
ALMOTRIPTAN MALATE
ALOGLIPTIN
ALOGLIPTIN/METFORM HCL
ALOGLIPTIN/PIOGLITAZONE
ALOSETRON
ALPHAGAN P
ALTACE
ALTOPREV
ALTRENO
ALUNBRIG
ALYQ
AMARYL
AMBIEN
AMBIEN CR
AMBRISENTAN
AMCINONIDE
AMERGE
AMICAR
AMITIZA
AMNESTEEM
AMOXICILLIN/CLAVULANATE POTASSIUM ER
AMPHETAMINE ER
AMPYRA
AMRIX
AMZEEQ
ANADROL-50
ANAFRANIL
ANALPRAM HC
ANALPRAM HC SINGLES
ANASPAZ
ANCOBON
ANDRODERM
ANDROGEL
ANDROGEL PUMP
ANTABUSE
ANUSOL-HC
APEXICON E
APIDRA
APIDRA SOLOSTAR
APLENZIN
APTENSIO XR
ARANESP
ARAVA
ARAZLO
ARCALYST
ARICEPT
ARIKAYCE
ARIMIDEX
ARISTADA
ARISTADA INITIO
ARIXTRA
ARMONAIR DIGIHALER
AROMASIN
ARTHROTEC 50
ARTHROTEC 75
ARYMO ER
ASACOL HD
ASPIRIN/OMEPRAZOLE
ATACAND
ATACAND HCT
ATELVIA
ATIVAN
ATRALIN
ATRIPLA
AUBAGIO
AUGMENTED BETAMETHASONE DIPROPIONATE
AUGMENTIN
AUGMENTIN ES
AUGMENTIN XR
AURYXIA
AUSTEDO
AUVI-Q
AVALIDE
AVAPRO
AVAR
AVAR LS
AVAR-E LS
AVELOX
AVITA
AVODART
AVONEX
AVONEX PEN
AYGESTIN
AYVAKIT
AZELEX
AZILECT
AZOR
AZULFIDINE
AZULFIDINE EN TABS
BACTRIM
BACTRIM DS
BAFIERTAM
BALVERSA
BANZEL
BARACLUDE
BECONASE AQ
BELBUCA
BELSOMRA
BELVIQ
BELVIQ XR
BENICAR
BENICAR HCT
BENLYSTA
BENZAC AC WASH
BENZACLIN
BENZACLIN PUMP
BENZAMYCIN
BENZEFOAM
BENZEFOAM ULTRA
BENZEPRO
BENZPHETAMINE
BEPREVE
BESER
BETAMETHASONE VALERATE
BETAPACE
BETAPACE AF
BETASERON
BETHKIS
BEXAROTENE
BEYAZ
BILTRICIDE
BIMATOPROST
BINOSTO
BLEPH-10
BONIVA
BONJESTA
BOSENTAN
BOSULIF
BP CLEANSING WASH
BPO
BRAFTOVI
BRAVELLE
BREZTRI AEROSPHERE
BRIVIACT
BRONCHITOL
BRONCHITOL TOLERANCE TEST
BRUKINSA
BRYHALI
BUDESONIDE ER
BUMEX
BUPAP
BUPHENYL
BUPRENORPHINE
BUPRIPION HYDROCHOLRIDE ER (XL)
BUTALBITAL/ACETAMINOPHEN
BUTALBITAL/ACETAMINOPHEN/ CAFFEINE
BUTRANS
BYDUREON
BYDUREON BCISE
BYDUREON PEN
BYETTA
BYNFEZIA PEN
BYVALSON
CABOMETYX
CADUET
CAFERGOT
CALAN
CALAN SR
CALCIPOTRIENE
CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE
CALQUENCE
CAMBIA
CAPECITABINE
CAPEX
CAPLYTA
CAPRELSA
CARAC
CARAFATE
CARBAGLU
CARBATROL
CARBINOXAMINE MALEATE
CARDIZEM
CARDIZEM CD
CARDURA
CARISOPRODOL
CARNITOR
CARNITOR SF
CAROSPIR
CASODEX
CATAPRES
CATAPRES-TTS
CAYSTON
CELEBREX
CELEXA
CELLCEPT
CEQUA
CERDELGA
CETROTIDE
CHENODAL
CHLORZOXAZONE
CHOLBAM
CHORIONIC GONADOTROPIN
CIALIS
CILOXAN
CIMETIDINE HCL
CIMETIDINE HYDROCHLORIDE
CIMZIA
CIMZIA STARTER KIT
CINACALCET HYDROCHLORIDE
CIPRO
CIPRODEX
CLARAVIS
CLARINEX
CLEOCIN
CLEOCIN PEDIATRIC
CLEOCIN-T
CLIMARA
CLINDAGEL
CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PHOSPHATE/TRETINOIN
CLOBETASOL PROPIONATE
CLOBETASOL PROPIONATE EMOLLIENT
CLOBEX
CLOCORTOLONE PIVALATE
CLOCORTOLONE PIVALATE PUMP
CLODAN
CLODERM
CLODERM PUMP
CLOVIQUE
CLOZAPINE ODT
CLOZARIL
COLAZAL
COLCHICINE
COLCRYS
COLESTID
COLESTID FLAVORED
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
CORVITA
CORVITE
CORVITE 150
CORZIDE
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
CYMBALTA
CYSTADROPS
CYSTARAN
CYTOMEL
CYTOTEC
D.H.E. 45
DAKLINZA
DALFAMPRIDINE ER
DANAZOL
DANTRIUM
DARAPRIM
DAURISMO
DAYPRO
DAYTRANA
DAYVIGO
DDAVP
DEFERASIROX
DEFERIPRONE
DELESTROGEN
DEMADEX
DEMECLOCYLCINE HCL
DEMOCLOCYCLINE HYDROCHLORIDE
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPO-TESTOSTERONE
DERMA-SMOOTH /FS BODY
DERMA-SMOOTH /FS SCALP
DERMOTIC
DESONATE
DESONIDE
DESOWEN
DESOXIMETASONE
DESOXYN
DESVENLAFAXINE ER
DETROL
DETROL LA
DEXCHLORPHENIRAMINE MALEATE
DEXCOM G6 RECEIVER
DEXCOM G6 SENSOR
DEXCOM G6 TRANSMITTER
DEXEDRINE
DEXILANT
DIBENZYLINE
DICLEGIS
DICLOFENAC
DICLOFENAC EPOLAMINE
DICLOFENAC SODIUM
DIDANOSINE
DIETHYLPROPION HCL
DIETHYLPROPION HCL ER
DIFFERIN
DIFICID
DIFLORASONE
DIFLUCAN
DIGOXIN
DIHYDROERGOTAMINE MESYLATE
DIMETHYL FUMARATE
DIOVAN
DIOVAN HCT
DIPROLENE
DIPROLENE AF
DITROPAN XL
DIURIL
DOJOLVI
DOPTELET
DORYX
DORYX MPC
DORZOLAMIDE HCL
DORZOLAMIDE HCL/TIMOLOL MALEATE
DOVONEX
DOXEPIN HYDROCHLORIDE
DOXYCYCLINE
DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE DR
DOXYCYCLINE MONOHYDRATE
DOXYLAMINE SUCCINATE/ PYRIDOXINE HYDROCHLORIDE
DRISDOL
DRIZALMA SPRINKLE
DROXIA
DUAC
DUAKLIR PRESSAIR
DUETACT
DUEXIS
DUOBRII
DUPIXENT
DURAGESIC
DYANAVEL XR
DYAZIDE
DYMISTA
E.E.S. GRANULES
EC-NAPROSYN
ECOZA
EDARBI
EDARBYCLOR
EDECRIN
EDLUAR
EFFEXOR XR
EFFIENT
EFUDEX
EGRIFTA
EGRIFTA SV
ELESTAT
ELETRIPTAN HYDROBROMIDE
ELIDEL
ELIMITE
ELMIRON
ELOCON
ELURYNG
EMADINE
EMBEDA
EMFLAZA
EMGALITY
EMTRICITABINE/TENOFOVIR DISOPROXIL
EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE
ENABLEX
ENBREL
ENBREL MINI
ENBREL SURECLICK
ENDARI
ENDOMETRIN
ENSPRYNG
ENSTILAR
ENTOCORT EC
EPANED
EPCLUSA
EPIDIOLEX
EPIDUO
EPIDUO FORTE
EPINEPHRINE
EPIPEN 2
-PAK
EPIPEN
-JR 2
-PAK
EPIVIR
EPIVIR HBV
EPOGEN
EPROSARTAN MESYLATE
EPZICOM
ERIVEDGE
ERLEADA
ERLOTINIB HYDROCHLORIDE
ERTACZO
ERY
ERYGEL
ERYPED 200
ESBRIET
ESOMEPRAZOLE STRONTIUM
ESTRACE
ESTROSTEP FE
ETODOLAC ER
ETONGESTREL/ETHINYL ESTRADIOL
ETOPOSIDE
EUCRISA
EVEKEO
EVEKEO ODT
EVEROLIMUS
EVOCLIN
EVOXAC
EVRYSDI
EVZIO
EXELDERM
EXELON
EXFORGE
EXFORGE HCT
EXJADE
EXTAVIA
EXTINA
EYSUVIS
EZALLOR SPRINKLE
FABIOR
FAMOTIDINE
FANAPT
FANAPT TITRATION PAK
FARXIGA
FARYDAK
FASENRA PEN
FAZACLO
FEBUXOSTAT
FELBATOL
FELDENE
FEMARA
FEMHRT LOW DOSE
FENOGLIDE
FENOPROFEN
FENORTHO
FENTANYL
FENTANYL CITRATE
FENTANYL CITRATE ORAL TRANSMUCOSAL
FENTORA
FERRIPROX
FETZIMA
FETZIMA TITRATION PACK
FEXMID
FINACEA
FINTEPLA
FIORICET
FIRAZYR
FIRDAPSE
FLAGYL
FLECTOR
FLOLIPID
FLOMAX
FLOXIN OTIC
FLUMADINE
FLUNISOLIDE
FLUOCINONIDE
FLURBIPROFEN
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
FROVA
FROVATRIPTAN SUCCINATE
FULPHILA
FURADANTIN
FUROSEMIDE
FYCOMPA
GABITRIL
GALAFOLD
GANIRELIX ACETATE
GASTROCROM
GATTEX
GAVRETO
GELNIQUE
GELNIQUE PUMP
GEMTESA
GENERESS FE
GENOTROPIN
GENOTROPIN MINIQUICK
GEODON
GILENYA
GILOTRIF
GIMOTI
GLATIRAMER ACETATE
GLATOPA
GLEEVEC
GLOPERBA
GLUCOSE TEST STRIPS**
GLUCOTROL
GLUCOTROL XL
GLUMETZA
GLYCOPYRROLATE
GLYDO
GLYNASE
GLYXAMBI
GOCOVRI
GONAL
-
F
GONAL
-F RFF
GONAL
-F RFF REDIJECT
GRALISE
GRANIX
GRASTEK
HAEGARDA
HALCION
HALDOL
HALDOL DECANOATE
HALOBETASOL PROPIONATE
HALOG
HARVONI
HELIDAC THERAPY
HEMADY
HEPSERA
HETLIOZ
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
HUMATROPE COMBO PACK
HUMIRA
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK
HUMIRA PEN
HUMIRA PEN-CD/UC/HS STARTER
HUMIRA PEN-PS/UV STARTER
HYCAMTIN
HYDREA
HYDROCODONE BITARTRATE ER
HYDROCODONE BITARTRATE/ CHLORPHENIRAMINE MALEATE/PSE
HYDROCORTISONE BUTYRATE
HYDROCORTISONE BUTYRATE (LIPID)
HYDROCORTISONE BUTYRATE (LIPOPHILIC)
HYDROMORPHONE HCL ER
HYDROMORPHONE HYDROCHLORIDE ER
HYSINGLA ER
HYZAAR
IBRANCE
ICAR-C PLUS
ICATIBANT ACETATE
ICLUSIG
ICOSAPENT ETHYL
IDHIFA
IMATINIB MESYLATE
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 LISPRO
INSULIN LISPRO JUNIOR KWIKPEN
INSULIN LISPRO KWIKPEN
INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN
INTERMEZZO
INTRAROSA
INTRON A
INTUNIV
INVEGA
INVEGA SUSTENNA
INVEGA TRINZA
INVOKAMET
INVOKAMET XR
INVOKANA
IOPIDINE
IRESSA
ISOPTO CARPINE
ISORDIL
ISOTRETINOIN
ISTALOL
ISTURISA
ITRACONAZOLE
IVERMECTIN
JADENU
JADENU SPRINKLE
JAKAFI
JALYN
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
JATENZO
JENTADUETO
JENTADUETO XR
JORNAY PM
JUBLIA
JUXTAPID
JYNARQUE
KADIAN
KALETRA
KALYDECO
KAPVAY
KARBINAL ER
KATERZIA
KAZANO
KEFLEX
KENALOG
KEPPRA
KEPPRA XR
KERYDIN
KESIMPTA
KETOCONAZOLE
KETODAN
KETOPROFEN
KETOPROFEN ER
KETOROLAC TROMETHAMINE
KEVEYIS
KEVZARA
KHEDEZLA
KINERET
KISQALI
KISQALI FEMARA
KITABIS PAK
KLARON
KLISYRI
KLONOPIN
KOMBIGLYZE XR
KORLYM
KOSELUGO
K-PHOS NEUTRAL
K-TAB
KUVAN
KYNMOBI
LAC-HYDRIN
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
LAPATINIB DITOSYLATE
LASIX
LASTACAFT
LATANOPROST
LATISSE
LATUDA
LAZANDA
LEDIPASVIR/SOFOSBUVIR
LENVIMA
LESCOL XL
LETAIRIS
LEUKINE
LEVAQUIN
LEVBID
LEVOBUNOLOL HCL
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
LIVALO
LOCOID
LOCOID LIPOCREAM
LODINE
LODOSYN
LOKELMA
LOMAIRA
LOMOTIL
LONHALA MAGNAIR REFILL KIT
LONHALA MAGNAIR STARTER KIT
LONSURF
LOPID
LOPRESSOR
LOPRESSOR HCT
LOPROX
LOPROX SHAMPOO
LORBRENA
LORZONE
LOSEASONIQUE
LOTEMAX
LOTENSIN
LOTENSIN HCT
LOTREL
LOTRISONE
LOTRONEX
LOVAZA
LOVENOX
LUBIPROSTONE
LULICONAZOLE
LUMIGAN
LUNESTA
LUPKYNIS
LUXIQ
LUZU
LYNPARZA
LYRICA
LYRICA CR
LYSODREN
LYSTEDA
LYUMJEV
LYUMJEV KWIKPEN
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
MEGACE ES
MEKINIST
MEKTOVI
MELOXICAM
MEMANTINE HYDROCHLORIDE
MEMANTINE HYDROCHLORIDE ER
MENOPUR
MEPHYTON
MEPRON
MESTINON
MESTINON TIMESPAN
METAXALL
METAXALONE
METFORMIN HYDROCHLORIDE
METFORMIN HYDROCHLORIDE ER
METHITEST
METHYLIN
METHYLPHENIDATE HCL
METHYLPHENIDATE HCL ER
METHYLPHENIDATE HCL ER (LA)
METHYLTESTOSTERONE
METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE
METROCREAM
METROGEL
METROGEL-VAGINAL
METROLOTION
MICARDIS
MICARDIS HCT
MICONAZOLE NITRATE/ZINC OXIDE/ WHITE PETROLATUM
MICORT-HC
MIGLUSTAT
MIGRANAL
MINASTRIN 24 FE
MINIPRESS
MINOCIN
MINOCYCLINE HYDROCHOLORIDE ER
MINOLIRA
MIRAPEX
MIRAPEX ER
MIRCERA
MIRCETTE
MOBIC
MONDOXYNE NL
MORPHABOND ER
MORPHINE SULFATE ER
MOTEGRITY
MOTOFEN
MOVANTIK
MS CONTIN
MULPLETA
MYALEPT
MYAMBUTOL
MYCAPSSA
MYCOBUTIN
MYDAYIS
MYDRIACYL
MYFORTIC
MYORISAN
MYRBETRIQ
MYSOLINE
NADOLOL/BENDROFLUMETHIAZIDE
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
NIZORAL
NOCDURNA
NOCTIVA
NOLIX
NORDITROPIN FLEXPRO
NORITATE
NORPRAMIN
NORTHERA
NORVASC
NOURIANZ
NOVAREL
NOXAFIL
NUBEQA
NUCALA
NUCORT
NUCYNTA ER
NUPLAZID
NURTEC
NUTROPIN AQ NUSPIN
NUTROPIN AQ PEN
NUVIGIL
NUZYRA
NYMALIZE
NYVEPRIA
OCALIVA
OCTREOTIDE ACETATE
OCUFLOX
ODACTRA
ODOMZO
OFEV
OKEBO
OLUMIANT
OLUX
OLUX-E
OMECLAMOX-PAK
OMEGA-3-ACID ETHYL ESTERS
OMEPPI
OMEPRAZONE/SODIUM BICARBONATE
OMNARIS
OMNIPOD 5 PACK
OMNIPOD DASH 5 PACK
OMNIPOD DASH SYSTEM
OMNIPOD STARTER KIT
OMNIPRED
OMNITROPE
ONEXTON
ONFI
ONGENTYS
ONGLYZA
ONUREG
ONZETRA XSAIL
OPSUMIT
ORACEA
ORALAIR
ORALAIR ADULT SAMPLE KIT
ORALAIR ADULT STARTER PACK
ORALAIR CHILDREN/ADOLESCENTS STARTER PACK
ORAPRED ODT
ORENCIA
ORENCIA CLICKJECT
ORENITRAM
ORFADIN
ORGOVYX
ORIAHNN
ORILISSA
ORKAMBI
ORLADEYO
ORTHO MICRONOR
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CYCLEN
ORTHO-NOVUM TAB 1/35
ORTHO-NOVUM TAB 7/7/7
ORTIKOS
OSENI
OSMOLEX ER
OSPHENA
OTEZLA
OTREXUP
OVACE PLUS
OVACE PLUS WASH
OVACE WASH
OVIDE
OVIDREL
OXANDROLONE
OXBRYTA
OXERVATE
OXICONAZOLE NITRATE
OXISTAT
OXSORALEN-ULTRA
OXYCODONE HCL ER
OXYCONTIN
OXYMORPHONE HYDROCHLORIDE ER
OZEMPIC
OZOBAX
PALFORZIA
PALYNZIQ
PAMELOR
PANDEL
PARLODEL
PARNATE
PATANASE
PAXIL
PAXIL CR
PAZEO
PEDIAPRED
PEGASYS
PEGASYS PROCLICK
PEG-INTRON
PEMAZYRE
PENICILLAMINE
PENLAC NAIL LACQUER
PENNSAID
PEPCID
PERCOCET
PERIDEX
PERSERIS
PEXEVA
PHENDIMETRAZINE
PHENDIMETRAZINE ER
PHENDIMETRAZINE TARTRATE
PHENDIMETRAZINE TARTRATE ER
PHENTERMINE HCL
PHRENILIN FORTE
PICATO
PIMECROLIMUS
PIQRAY 200MG DAILY DOSE
PIQRAY 250MG DAILY DOSE
PIQRAY 300MG DAILY DOSE
PLAQUENIL
PLAVIX
PLEGRIDY
PLEGRIDY STARTER PACK
PLEXION
PLEXION CLEANSER
PLEXION CLEANSING CLOTHS
PLIAGLIS
POLYTRIM
POMALYST
POSACONAZOLE
POSACONAZOLE DR
PR BENZOYL PEROXIDE
PRALUENT
PRAMOSONE
PRANDIN
PRAVACHOL
PRECOSE
PRED FORTE
PREDNICARBATE
PREDNISOLONE ACETATE
PREDNISOLONE ACETATE P-F
PREGNYL
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
PROZAC
PRUDOXIN
PSORCON
PULMICORT
PYLERA
PYRIDIUM
QBRELIS
QBREXA
QDOLO
QINLOCK
QMIIZ ODT
QNASL
QNASL CHILDRENS
QSYMIA
QTERN
QUALAQUIN
QUARTETTE
QUDEXY XR
QUESTRAN
QUESTRAN LIGHT
QUILLICHEW ER
QUILLIVANT XR
RABEPRAZOLE SODIUM DR SPRINKLE
RAGWITEK
RAMELTEON
RAPAFLO
RAPAMUNE
RASUVO
RAVICTI
RAYALDEE
RAYOS
RAZADYNE
RAZADYNE ER
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
REDITREX
REGLAN
REGRANEX
RELAFEN DS
RELEXXII
RELISTOR
RELPAX
RELTONE
REMERON
REMERON SOLTAB
RENAGEL
RENVELA
REPATHA
REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK
REQUIP
REQUIP XL
RESTASIS
RESTASIS MULTIDOSE
RESTORIL
RETACRIT
RETEVMO
RETIN-A
RETIN-A MICRO
RETIN-A MICRO PUMP
RETROVIR
REVATIO
REVCOVI
REVLIMID
REXULTI
REYVOW
RHOPRESSA
RIAX
RIFADIN
RILUTEK
RIMANTADINE HYDROCHLORIDE
RINVOQ
RIOMET
RIOMET ER
RISPERDAL
RISPERDAL CONSTA
RESPERIDONE ODT
RITALIN
RITALIN LA
ROBAXIN
ROBAXIN-750
ROCALTROL
ROCKLATAN
ROSADAN KIT
ROWASA
ROZEREM
ROZLYTREK
RUBRACA
RUFINAMIDE
RUZURGI
RYBELSUS
RYDAPT
RYTHMOL SR
SABRIL
SAFYRAL
SAIZEN
SAIZEN PREP RECONSTRUCTION KIT
SALAGEN
SALEX
SALEX CREAM
SAMSCA
SANDOSTATIN
SAPHRIS
SAPROPTERIN DIHYDROCHLORIDE
SAXENDA
SEASONIQUE
SECUADO
SEGLUROMET
SENSIPAR
SERNIVO
SEROQUEL
SEROQUEL XR
SEROSTIM
SEVELAMER HYDROCHLORIDE
SEYSARA
SIGNIFOR
SIKLOS
SILDENAFIL CITRATE
SILENOR
SILIQ
SILVADENE
SIMPONI
SIMVASTATIN
SINEMET
SINEMET CR
SINGULAIR
SITAVIG
SKELAXIN
SKLICE
SKYRIZI
SLYND
SODIUM PHENYLBUTYRATE
SODIUM SULFACETAMIDE/SULFUR
SODIUM SULFACETAMIDE/ SULFUR CLEANSER IN UREA
SOFOSBUVIR/VELPATASVIR
SOLIQUA 100/33
SOLODYN
SOLOSEC
SOLTAMOX
SOMA
SOMAVERT
SOOLANTRA
SORIATANE
SORILUX
SOTYLIZE
SOVALDI
SPORANOX
SPORANOX PULSEPAK
SPRIX
SPRYCEL
SSS 10-5
STARLIX
STEGLATRO
STEGLUJAN
STELARA
STIVARGA
STRATTERA
STRENSIQ
STRIANT
SUBSYS
SUCRAID
SUCRALFATE
SULAR
SULCONAZOLE NITRATE
SULFAMYLON
SUMADAN WASH
SUMADAN XLT
SUMATRIPTAN SUCCINATE
SUMATRIPTAN /NAPROXEN SODIUM
SUMAXIN
SUMAXIN WASH
SUNOSI
SUPRAX
SURMONTIL
SUTENT
SYLATRON
SYMBYAX
SYMDEKO
SYMPROIC
SYNALAR
SYNDROS
SYNERA
SYNJARDY
SYNJARDY XR
SYPRINE
TABRECTA
TACLONEX
TACROLIMUS
TADALAFIL
TAFINLAR
TAGRISSO
TAKHZYRO
TALICIA
TALTZ
TALZENNA
TAPAZOLE
TARCEVA
TARGADOX
TARGRETIN
TASIGNA
TASMAR
TAVABOROLE
TAVALISSE
TAYTULLA
TAZAROTENE
TAZORAC
TAZVERIK
TECFIDERA
TECFIDERA STARTER PACK
TEGSEDI
TEKTURNA
TEKTURNA HCT
TEMODAR
TEMOVATE
TEMOZOLOMIDE
TENORETIC
TENORMIN
TEPMETKO
TERIPARATIDE
TESSALON PERLES
TESTIM
TESTOSTERONE
TESTOSTERONE CYPIONATE
TESTOSTERONE ENANTHATE
TESTOSTERONE PUMP
TESTOSTERONE TOPICAL SOLUTION
TETRABENAZINE
TETRACYCLINE HYDROCHLORIDE
TEXACORT
THALOMID
THYQUIDITY
TIAZAC
TIBSOVO
TIGAN
TIGLUTIK
TIKOSYN
TIMOLOL MALEATE OPTHALMIC GEL FORMING
TIMOPTIC
TIMOPTIC-XE
TINDAMAX
TINIDAZOLE
TIROSINT
TIVORBEX
TIZANIDINE HCL
TIZANIDINE HYDROCHLORIDE
TOBI
TOBI PODHALER
TOBRADEX
TOBRAMYCIN
TOBREX
TOFRANIL
TOLAK
TOLMETIN SODIUM
TOLSURA
TOLVAPTAN
TOPAMAX
TOPAMAX SPRINKLE
TOPICORT
TOPIRAMATE ER
TOPROL XL
TOSYMRA
TOVET
TOVIAZ
TRACLEER
TRADJENTA
TRAMADOL HCL ER
TRANXENE T
TRAVATAN Z
TRAVOPROST
TREMFYA
TRETINOIN
TRETINOIN MICROSPHERE
TRETINOIN MICROSPHERE PUMP
TREXALL
TREXIMET
TRIAMCINOLONE ACETONIDE
TRIANEX
TIBENZOR
TRICOR
TRIDESILON
TRIENTINE HYDROCHLORIDE
TRIFLURIDINE
TRIJARDY XR
TRIKAFTA
TRILEPTAL
TRILIPIX
TRI-NORINYL 28
TRINTELLIX
TROKENDI XR
TRULANCE
TRULICITY
TRUSOPT
TUDORZA PRESSAIR
TUKYSA
TURALIO
TUSSIONEX PENNKINETIC EXTENDED RELEASE
TWYNSTA
TYKERB
TYMLOS
UBRELVY
UCERIS
UDENYCA
UKONIQ
ULORIC
ULTRAVATE
UPTRAVI
URECHOLINE
UROCIT-K
UROGESIC-BLUE
UROXATRAL
URSO 250
URSO FORTE
VALCYTE
VALIUM
VALTOCO
VALTREX
VANATOL LQ
VANATOL S
VANCOCIN
VANCOCIN HCL
VANOS
VASCEPA
VASERETIC
VASOTEC
VECAMYL
VELPHORO
VELTASSA
VELTIN
VENCLEXTA
VENCLEXTA STARTING PACK
VERDESO
VEREGEN
VERELAN
VERQUVO
VERSACLOZ
VERZENIO
VESICARE
VESICARE LS
VFEND
V-GO 20
V-GO 30
V-GO 40
VIBERZI
VIBRAMYCIN
VICTOZA
VIDEX EC
VIEKIRA PAK
VIGAMOX
VIIBRYD
VIIBRYD STARTER PACK
VIMOVO
VIMPAT
VIRAMUNE
VIRAMUNE XR
VIRAZOLE
VIROPTIC
VISTARIL
VITRAKVI
VIVLODEX
VIZIMPRO
VOGELXO
VOGELXO PUMP
VORICONAZOLE
VOSEVI
VOTRIENT
VRAYLAR
VTOL LQ
VUMERITY
VUSION
VYLEESI
VYNDAMAX
VYNDAQEL
VYTORIN
VYVANSE
VYZULTA
WAKIX
WELCHOL
WELLBUTRIN XL
WELLBUTRIN SR
WINLEVI
WIXELA INHUB
WYNZORA
XADAGO
XALATAN
XALKORI
XANAX
XANAX XR
XATMEP
XELJANZ
XELJANZ XR
XELODA
XELPROS
XENAZINE
XENICAL
XENLETA
XEPI
XERESE
XERMELO
XHANCE
XIFAXAN
XIGDUO XR
XIIDRA
XIMINO
XOLAIR
XOLEGEL
XOPENEX
XOSPATA
XPOVIO ONCE WEEKLY
XPOVIO TWICE WEEKLY
XTAMPZA ER
XTANDI
XULTOPHY 100/3.6
XYOSTED
XYREM
XYWAV
YASMIN 28
YAZ
YONSA
YOSPRALA
YUPELRI
ZACLIR CLEANSING
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
ZOLPIMIST
ZOMACTON
ZOMIG
ZOMIG ZMT
ZONALON
ZONEGRAN
ZORBTIVE
ZORVOLEX
ZOVIRAX
ZTLIDO
ZYCLARA
ZYCLARA PUMP
ZYDELIG
ZYFLO CR
ZYKADIA
ZYLOPRIM
ZYMAXID
ZYPITAMAG
ZYPREXA
ZYPREXA RELPREVV
ZYPREXA ZYDIS
ZYTIGA
ZYVOX

**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.