RX Select Prior Authorization List
The following is a list of drugs that require Prior Authorization under the Coventry RX Select Program. Please note that this Prior Authorization list is subject to change.
Prior Authorization
Accutane (isotretinoin) Actiq (transmucosal fentanyl) Byetta (exenatide) Copegus (ribavirin) Daytrana (methylphenidate) Exjade (deferasirox) Exubera (insulin human [rDNA origin]) Fentora (fentanyl buccal tablet) Janumet (sitagliptin/metformin) Januvia (sitagiptin phosphate) Gleevec (imatinib) Invega (paliperidone) Iressa (gefitinib) Letairis (ambrisentan) Lyrica (pregabalin) Nexavar (sorafenib) Noxafil (posaconazole) Opana IR (oxymorphone) OxyContin (oxycodone sustained release) Provigil (modafinil) Qualaquin (quinine) Ranexa (renolazine extended-release) Rebetol (ribavirin) Revatio (sildenafil) Revlimid (lenalidomide) Sporanox capsule & oral (itraconazole)
Sprycel (dasatinib) Sutent (sunitinib) Symlin (pramlintide) Tarceva (erlotinib) Temodar (temozolomide) Testosterone Products (Testim, Androgel, Striant, Androderm, Testoderm) Thalomid (thalidomide) Tracleer (bosentan) Tykerb (lapatinib) Ventavis (iloprost) Vfend (voriconazole) Xeloda (capecitabine) Xyrem (Sodium Oxybate) Zavesca (Miglustat) Zolinza (vorinostat) Zyvox (linezolid)
Step Therapy
Ambien CR (zolpidem extended release) Amitiza (lubiprostone) Cymbalta (duloxetine) Lunesta (eszopiclone) Pulmicort Respules (budesonide) Rozerem (ramelteon) Sensipar (cinacalcet) Sonata (zaleplon)
Only your physician can provide the information necessary to complete the prior authorization process. If you have been prescribed one of the drugs listed above, make sure your doctor knows that this medication requires prior authorization and they should contact Coventry Health Care at the phone number listed on your ID card. Drugs listed in bold are formulary. (8/2007)