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 = 35)
Agalsidase (FABRAZYME)
Alglucerase (CEREDASE)
Alpha1-proteinase inhibitor (PROLASTIN)
Anakinera (KINERET)
Aripiprazole (ABILIFY)
Atorvastatin (LIPITOR)
Azelaic acid (AZELEX) (Ages = 35)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

S
Sargramostim (all types)
Sodium hyaluronate-PVP-Enoxolone oral gel (GELCLAIR)

T
Tamsulosin (FLOMAX)
Tazarotene (TAZORAC)
Tegaserod (ZELNORM)
Temozolomide (TEMODAR)
Terbinafine oral (LAMISIL)
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
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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