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

A
Adapalene (DIFFERIN) (Ages > 35)
Adalimumab (HUMIRA)
Alglucerase (CEREDASE)
Alpha1-proteinase inhibitor (PROLASTIN)
Amlexanox (APHTHASOL)
Anakinera (KINERET)
Atomoxetine (STRATTERA)
Atorvastatin (LIPITOR)
Azelaic acid (AZELEX) (Ages > 35)

B
Becaplermin (REGRANEX gel)

C
Calcipotriene (DOVONEX)
Cetirizine HCl (ZYRTEC)
Ciclopirox solution (PENLAC)
Ciprofloxacin (CILOXAN)
Citalopram (CELEXA)

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

E
Entacapone (COMTAN)
Epoetin alfa (EPOGEN, PROCRIT)
Epoprostenol (FLOLAN)
ESKALITH
Etanercept (ENBREL)
Ezetimibe (ZETIA)

F
Fenofibrate (TRICOR brand only)
Fexofenadine HCl (ALLEGRA)
Filgrastim (NEUPOGEN)
Finasteride (PROSCAR)
Fluconazole (DIFLUCAN)
Fluticasone propionate/salmeterol inhalation powder (ADVAIR DISKUS)
Follitropin alfa (GONAL-F)
Fomivirsen (VITRAVENE)

G
Ganciclovir (oral CYTOVENE)
Glatiramer (COPAXONE)
Goserelin (ZOLADEX)

H
Human growth hormone (Humatrope brand — all other brands excluded)
Hyaluronan injections (SYNVISC)
Hyaluronate-PVP-Enoxolone oral gel (GELCLAIR)

I
Imatinib mesylate (GLEEVEC)
Imiglucerase (CEREZYME)
Infliximab (REMICADE)
Insulin infusion pumps (NOVOPEN or equivalent)
Interferon (all types, including BETASERON, AVONEX, REBIF)
Itraconazole (SPORANOX)

L
Leflunomide (ARAVA)
Leuprolide (LUPRON)
Levetiracetam (KEPPRA)
Levofloxacin (QUIXIN)
Losartan (COZAAR)
Losartan/hydrochlorothiazide (HYZAAR)

M
Menotropins (HUMEGON, PERGONAL)
Modafinil (PROVIGIL)
Montelukast (SINGULAIR)
Moxifloxacin ophthalmic solution (VIGAMOX)

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

O
Ofloxacin (FLOXIN)
Ofloxacin ophthalmic solution (OCUFLOX)
Oprelvekin (NEUMEGA)
Oseltamivir (TAMIFLU)
Oxcarbazepine (TRILEPTAL)

P
Palivizumab (SYNAGIS)
Paroxetine (PAXIL)
Pegfilgrastim (NEULASTA)
Peginterferon alfa-2b (PEG-INTRON)
Pimecrolimus topical (ELIDEL)
Pioglitazone (ACTOS)
Progesterone gel (CRINONE)

R
Rabeprazole sodium (ACIPHEX)
Repaglinide (PRANDIN)
Rimantadine (FLUMADINE)
Rizatriptan (MAXALT, MAXALT MLT)
Rofecoxib (VIOXX)
Rosiglitazone (AVANDIA)

S
Sargramostim (all types)
Sodium Hyaluronate-PVP-Enoxolone oral gel (GELCLAIR)
Sumatriptan tablets (IMITREX)

T
Tacrolimus topical (PROTOPIC)
Tamsulosin (FLOMAX)
Tazarotene (TAZORAC)
Terbinafine oral (LAMISIL)
Testosterone 1% gel (ANDROGEL)
Teriparatide injection (FORTEO)
Thyrotropin alfa (THYROGEN)
Tizanidine (ZANAFLEX)
Tolcapone (TASMAR)
Topiramate (TOPAMAX)
Trastuzumab (HERCEPTIN)
Tretinoin (AVITA, RETIN-A) (Ages > 35)

U
Urofollitropin (FERTINEX, METRODIN)

V
Valsartan (DIOVAN)
Valsartan/hydrochlorothiazide (DIOVAN HCT)
Verteporfin (VISUDYNE)
Voriconazole (VFEND)

Z
Zolpidem (AMBIEN)
Zonisamide (ZONEGRAN)

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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