The medications on this page require prior authorization by Dean Health Plan. Brand names (in capital letters) are listed for informational purposes only.

A
Adalimumab (HUMIRA)
Adapalene (DIFFERIN) (Ages > or = 35)
Agalsidase (FABRAZYME)
Alglucerase (CEREDASE)
Alpha1-proteinase inhibitor (PROLASTIN)
Anakinera (KINERET)
Apomorphine HCI (APOKYN)
Aripiprazole (ABILIFY)
Atorvastatin (LIPITOR)
Azelaic acid (AZELEX) (Ages > or = 35)

B
Becaplermin (REGRANEX gel)
Buprenorpine HCI/Nalazone (SUBOXONE)
Bupropion HCl (WELLBUTRIN XL)

C
Celecoxib (CELEBREX)
Cetirizine HCl (ZYRTEC)
Cyclosporine ophthalmic emulsion (RESTASIS)

D
Darbepoetin (ARANESP)
Desmopressin (STIMATE)
Dexmethylphenidate (FOCALIN)
Diazepam rectal gel (DIASTAT)
Dofetilide (TIKOSYN)

E
Enfuvirtide (FUZEON)
Entacapone (COMTAN)
Eplerenone (INSPRA) (step therapy)
Epoetin alfa (EPOGEN, PROCRIT)
Epoprostenol (FLOLAN)
Etanercept (ENBREL)

F
Fexofenadine HCl (ALLEGRA) (step therapy)
Filgrastim (NEUPOGEN)
Follitropin alfa (GONAL-F)
Fomivirsen (VITRAVENE)

G
Ganciclovir (oral CYTOVENE)
Gefitinib (IRESSA)
Glatiramer (COPAXONE)
Goserlin (ZOLADEX)

H
Human growth hormone — Somatropin (Humatrope brand — all other brands excluded)

I
Ibritumomab tiuxetan (ZEVALIN)
Imatinib mesylate (GLEEVEC)
Imiglucerase (CEREZYME)
Infliximab (REMICADE)
Insulin infusion pumps
Interferon alfa-2a (ROFERON)
Interferon alfa-2b (INTRON A)
Interferon n3 (ALFERON N)
Interferon beta (AVONEX, BETASERON, REBIF)
Itraconazole (SPORANOX)

K
K Sorbate/He-Cal/PVP/Hyalur AC (GELCLAIR)

L
Leflunomide (ARAVA)
Leuprolide (LUPRON)
Leuprolide/lidocaine (VIADUR)
Levetiractam (KEPPRA)
Linezoild (ZYVOX)

M
Menotropins (HUMEGON, PERGONAL)
Modafinil (PROVIGIL)
Montelukast (SINGULAIR)

N
Nafarelin (SYNAREL)
Naltrexone (REVIA)
Nateglinide (STARLIX)
Norethindrone/ethinyl estradiol (ESTROSTEP)
Norethindrone acetate/ethinyl estradiol (MICROGESTIN, MICROGESTIN FE)

O
Ofloxacin oral (FLOXIN)
Omalizumab (XOLAIR)
Oseltamivir (TAMIFLU)
Oxcarbazepine (TRILEPTAL)

P
Palivizumab (SYNAGIS)
Pantoprazole (PROTONIX)
Pegfilgrastim (NEULASTA)
Peginterferon alfa-2b (PEG-INTRON)
Pegvisomant (SOMAVERT)
Pioglitazone (ACTOS) (step therapy)
Progesterone gel (CRINONE)

R
Rabeprazole (ACIPHEX)
Repaglinide (PRANDIN)
Rizatriptan (MAXALT, MAXALT MLT)
Rosiglitazone (AVANDIA) (step therapy)
Rosiglitazone/metformin (AVANDAMET) (step therapy)

S
Sargramostim (all types)

T
Tamsulosin (FLOMAX) (step therapy)
Tazarotene (TAZORAC)
Tegaserod (ZELNORM)
Telithromycin (KETEK)
Temozolomide (TEMODAR)
Terbinafine oral (LAMISIL)
Teriparatide injection (FORTEO)
Thyrotropin alfa (THYROGEN)
Tizanidine (ZANAFLEX)
Tolcapone (TASMAR)
Topiramate (TOPAMAX)
Trastuzumab (HERCEPTIN)
Tretinoin (AVITA, RETIN-A) (Ages > or = 35)

U
Urofollitropin (FERTINEX, METRODIN)

V
Valganciclovir (VALCYTE)
Verteporfin (VISUDYNE)
Voriconazole (VFEND)

Z
Zolpidem (AMBIEN)

As drugs are approved by the U.S. Food and Drug Administration, we may add them to this list. Your physician or your pharmacist should fill out a Drug Prior-Authorization Request Form. For urgent authorizations, your physician should call Customer Service.

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