The medications on this page require prior authorization by Dean Health Plan.
Brand names (in capital letters) are listed for informational purposes only.
[ A | B | C | D | E | F | G | H | I | L | M | N | O | P | R | S | T | U | V | Z ]
A
Adapalene (DIFFERIN)
(Ages > 35)
Alglucerase (CEREDASE)
Alpha1-proteinase inhibitor (PROLASTIN)
Amlexanox (APHTHASOL)
Atorvastatin (LIPITOR)
Azelaic acid (AZELEX)
(Ages > 35)
B
Becaplermin (REGRANEX
gel)
C
Calcipotriene (DOVONEX)
Ciclopirox solution (PENLAC)
CONCETA
D
Desmopressin (STIMATE)
Diazepam rectal gel
(DIASTAT)
Dofetilide (TIKOSYN)
Donepezil (ARICEPT)
Dornase alfa (PULMOZYME)
E
Entacapone (COMTAN)
Epoetin alpha (EPOGEN,
PROCRIT)
Epoprostenol (FLOLAN)
ESKALITH
Etanercept (ENBREL)
F
Fenofibrate (TRICOR
brand only)
Filgrastim (NEUPOGEN)
Finasteride (PROSCAR)
Fluconazole (DIFLUCAN)
Fluoxetine (PROZAC)
Fluticasone propionate/
salmeterol inhalation
powder (ADVAIR DISKUS)
Follitropin alfa (GONAL-F)
Fomivirsen (VITRAVENE)
G
Galantamine (REMINYL)
Ganciclovir (oral CYTOVENE)
Glatiramer (COPAXONE)
Goserelin (ZOLADEX)
H
Human growth hormone
(all types)
Hyaluronan injections
(SYNVISC)
I
Imatinib mesylate (GLEEVAC)
Imiglucerase (CEREZYME)
Infliximab (REMICADE)
Insulin infusion pumps
(NOVOPEN or equivalent)
Interferon (all types, including
BETASERON, AVONEX)
Intraconazole (SPORANOX)
L
Lansoprazole (PREVACID)
Leflunomide (ARAVA)
Leuprolide (LUPRON)
Levetiractam (KEPPRA)
Losartan (COZAAR)
Losartan/hydrochlorothiazide
(HYZAAR)
M
Menotropins (HUMEGON,
PERGONAL)
Modafanil (PROVIGIL)
N
Nafarelin (SYNAREL)
Naltrexone (REVIA)
Nateglinide (STARLIX)
Norethindrone/ethinyl estradiol
(ESTROSTEP, ORTHONOVUM
7-7-7)
Norgestimate ethinyl estradiol
(ORTHO-CYCLEN,
ORTHO TRI-CYCLEN)
O
Ofloxacin (FLOXIN)
Oprelvekin (NEUEMEGA)
Oseltamivir (TAMIFLU)
Oxcarbazine (TRILEPTAL)
P
Palivizumab (SYNAGIS)
Peginterferon alfa 2b
(PEG-INTRON)
Pioglitazone (ACTOS)
Progesterone—gel
(CRINONE)—oral
(PROMETRIUM),
all other oral excluded
R
Raloxifene (EVISTA)
Repaglinide (PRANDIN)
Rimantadine (FLUMADINE)
Rivastigmine (EXELON)
Rizatriptan (MAXALT,
MAXALT MLT)
Rofecoxib (VIOXX)
Rosiglitazone (AVANDIA)
S
Sargramostim (all types)
T
Tacrolimus topical (PROTOPIC)
Tamsulosin (FLOMAX)
Tazarotene (TAZORAC)
Terbinafine (oral LAMISIL)
Thyrotropin alfa (THYROGEN)
Tizanidine (ZANAFLEX)
Tolcapone (TASMAR)
Tramadol (ULTRAM)
Trastuzumab (HERCEPTIN)
Tretinoin (AVITA, RETIN-A)
(Ages > 35)
U
Urofollitropin (FERTINEX,
METRODIN)
V
Valsartan (DIOVAN)
Valsartan/hydrochlorothiazide
(DIOVAN HCT)
Verteporfin (VISUDYNE)
Z
Zolmitriptan (ZOMIG)
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
our Customer Service
Department.
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