Drug authorization forms

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Drug-specific authorization forms

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

Abilify® form Medicare only (01/2017)
Abstral® forms Commercial (11/2017) or Medicare (11/2017)
Acitretin® form Medicaid only (02/2018)
Actemra® forms Commercial (03/2018) or Medicare (01/2017)
Acthar® forms Commercial (03/2018)
Actimmune® form Medicare only (03/2018)
Actiq® forms Commercial (11/2017) or Medicare (11/2017)
Adcetris® form Commercial & Medicaid only (01/2018)
Adcirca® forms Commercial (02/2018) or Medicaid (02/2018) or Medicare (07/2017)
Adempas® forms Commercial (03/2018) or Medicaid (02/2018) or Medicare (01/2018)
Adlyxin® form MyPriority only (07/2017)
Afinitor® forms Commercial & Medicaid (03/2018) or Medicare (03/2018)
Aldurazyme® forms Commercial & Medicaid (03/2018)
Alecensa® forms Commercial (03/2018) or Medicare (03/2018)
Aliqopa® forms Commercial (01/2018) or Medicaid (01/2018)
Alogliptin forms MyPriority (03/2017) or Medicaid (02/2018)
Alunbrig® forms Commercial (07/2017) or Medicare (01/2018)
Amitriptyline form Medicare only (01/2018)
Amnesteem® form Commercial only (05/2017)
Ampyra® forms Commercial (02/2018) or Medicaid (02/2018) or Medicare (11/2017)
Anzemet®Medicare Part B vs. Part D determination (09/2017)
Aptiom® form Commercial only (01/2018)
Aralast NP forms Commercial & Medicaid (03/2018) or Medicare (03/2018)
Aranesp®  Medicaid (02/2018) or Medicare Part B vs. Part D determination (09/2017)
Aripiprazole form Medicare only (01/2018)
Armodafinil forms Commercial (09/2017) or Medicare (01/2017)
Arymo™ ER form MyPriority only (09/2017)
Arzerra® form Commercial & Medicaid only (11/2017)
Aubagio® form MyPriority only (05/2017)
Auryxia ™ form Commercial only (01/2018)
Austedo™ forms Commercial (01/2018) or Medicare (03/2018)
Aveed® forms Commercial (11/2017) or Medicare (11/2017)
Avonex® forms MyPriority (05/2017) or Medicaid (02/2018)
Azathioprine form Medicare Part B vs. Part D determination only (11/2017)

B

Banzel® forms Commercial (09/2017) or Medicare (09/2017)
Bavencio® form Commercial only (03/2018)
Belbuca™ form MyPriority only (09/2017)
Beleodaq® forms Commercial & Medicaid (09/2017) or Medicare (09/2017)
Benlysta® form Commercial & Medicaid only (03/2018)
Berinert® forms Commercial (01/2018) or Medicare (01/2017)
Besponsa® form Commercial & Medicaid only (11/2017)
Betaseron® form MyPriority only (05/2017)
Bethkis® forms Commercial (02/2018) or Medicaid (02/2018)
Blincyto® forms Commercial & Medicaid (03/2018) or Medicare (03/2017)
Boniva® form Commercial only (01/2018)
Bosulif® forms Commercial (03/2018) or Medicare (07/2017)
Botulinum toxin forms Commercial & Medicaid (04/2018) or Medicare (01/2016)
Brineura™ form Commercial only (07/2017)
Briviact® form Commercial only (03/2018)
Buphenyl® form Commercial only (03/2018)
Buprenorphine and naloxone form Medicare only (01/2018)
Buprenorphine transdermal patch form MyPriority only (09/2017)
Bydureon® form MyPriority only (11/2017)
Byetta® form MyPriority only (11/2017)

C

Cabometyx™ forms Commercial (01/2018) or Medicare (11/2017)
Calquence® forms Commercial (01/2018) or Medicare (03/2018)
Caprelsa® forms Commercial (07/2017) or Medicare (07/2017)
Carbaglu® forms Commercial (11/2017) or Medicare (11/2017)
Cayston® forms Commercial (02/2018) or Medicaid (02/2018) or MyPriority (07/2017)
Cerezyme® form Commercial and Medicaid only (05/2017)
Cholbam™ forms Commercial (07/2017) or Medicare (01/2018)
Chorionic gonadotropin form Medicare only (01/2018)
Cialis® form Medicare only  (01/2018)
Cimzia® forms Commercial (03/2018) or Medicare (03/2017)
Cinqair® forms Commercial & Medicaid (01/2018) or Medicare (07/2017)
Cinryze® form Commercial only (03/2017)
Claravis®  forms Commercial (05/2017) or Medicaid (03/2018)
Cometriq™ forms Commercial (07/2017) or Medicare (07/2017)
Copaxone® form Medicare only (01/2017)
Cosentyx® forms Commercial (03/2013) or Medicare (01/2017)
Cotellic® forms Commercial (05/2017) or Medicare (01/2018)
Crinone® form Medicare only (01/2018)
Cyramza® form Commercial & Medicaid only (07/2017)

D

Daklinza® forms Commercial group (11/2017) or MyPriority (11/2017) or Medicare (01/2018)
Daliresp® forms Commercial (09/2017) or Medicare (09/2017)
Dalvance® form Commercial (09/2016)
Daraprim® form Medicaid only (02/2018)
Depen® form Commercial only (03/2018)
Desmopressin form Medicaid only (03/2018)
Diabetic test strips form Medicare Part B only (01/2018)
Diclofenac 3% gel form Medicaid only (04/2018)
Digoxin form Medicare only (01/2018)
Dronabinol forms Medicaid (03/2018) or Medicare Part B vs. Part D determination (07/2017)
Duopa® form Commercial only (03/2018)
Dupixent® forms Commercial (07/2017) or Medicare (03/2018)

E

Elaprase® form Commercial & Medicaid only (05/2017)
Elavil® form Medicare only (01/2016)
Elelyso® form Commercial and Medicaid only (05/2017)
Embeda® form MyPriority only (09/2017)
Emend® form Medicare Part B vs Part D determination (07/2017)
Enbrel® forms Commercial (03/2018) or Medicaid (02/2018) or Medicare (09/2017)
Entresto® forms Commercial (02/2018) or Medicaid (02/2018) 
Entyvio® form Commercial & Medicaid only (09/2017)
Epclusa® forms Commercial group (11/2017) or MyPriority (11/2017) or Medicare (06/2017)
Epogen® forms Medicaid (02/2018) or Medicare Part B vs. Part D determination (09/2017)
Erbitux® forms Commercial & Medicaid (09/2017) or Medicare (09/2017)
Erivedge® forms Commercial & Medicaid (07/2017) or Medicare (09/2017)
Erwinaze® form Commercial & Medicaid only (07/2017)
Esbriet® forms Commercial (01/2017) or Medicare (01/2018)
Eszopiclone form Medicare only (01/2018)
Eylea® form Commercial & Medicaid only (11/2017)
Extavia® form MyPriority only (01/2017)

F

Fabrazyme® form Commercial & Medicaid only (01/2018)
Farxiga® form MyPriority only (01/2018)
Farydak™ forms Commercial & Medicaid (05/2017) or Medicare (05/2017)
Fasenra™ forms Commercial and Medicaid  (01/2018) or Medicare (03/2018)
Fentanyl citrate lozenge forms Commercial (11/2017) or Medicare (11/2017)
Fentanyl transdermal patch form MyPriority only (09/2017)
Fentora® forms Commercial (11/2017) or Medicare (11/2017)
Firazyr® forms Commercial (11/2017) or Medicare (11/2017)
Flector™ form Medicare only (05/2017)
Flolan® form Commercial and Medicaid only (07/2016)
Fluorouracil form Medicaid only (04/2018)
Forteo® forms Commercial (09/2017) or Medicaid (03/2018) or Medicare (01/2017)

G

Gattex® forms Commercial (07/2017) or Medicare (07/2017)
Gazyva® forms Commercial (01/2018) or Medicare (11/2016)
Gilenya® form Medicaid only (02/2018)
Gilotrif® forms Commercial (03/2018) or Medicare (11/2017)
Glassia® forms Commercial (03/2018) or Medicare (03/2018)
Glatopa /Glatiramer acetate forms MyPriority (10/2017) or Medicaid (02/2018)
Gleevec® forms Commercial (07/2017)
Glyxambi® form MyPriority only (01/2018)
Gralise® form Commercial only (07/2017)
Granisetron form Medicare Part B vs. Part D determination (09/2016)
Granix® form Medicaid only (02/2018)

H

Haegarda® forms Commercial (09/2017) or Medicare (09/2017)
Harvoni®
 forms Commercial group (11/2017) or MyPriority (11/2017) or Medicare (01/2018)
Hemlibra® form Commercial only (01/2018)
Hetlioz® forms Commercial (11/2017) or Medicare (11/2017)
Human growth hormone forms Commercial group (01/2018) or Medicaid (02/2018) or MyPriority (01/2018) or Medicare (11/2017)
Humira® forms Commercial (03/2018) or Medicaid (03/2018) or Medicare (03/2018)
Hydromorphone ER form MyPriority only (09/2017)
Hydroxprogesterone Caproate form Commercial & Medicaid (12/2016)
Hysingla ER® forms Commercial (03/2018) or Medicare (03/2018)

I

Ibrance® forms Commercial (03/2018) or Medicare (03/2018)
Iclusig® forms Commercial (07/2017) or Medicare (07/2017)
Idhifa™ form Medicare only (03/2018)
Ilaris® forms Commercial (11/2017) or Medicare (11/2017)
Imbruvica® forms Commercial (03/2018) or Medicare (03/2018)
Imfinzi™ form Commercial and Medicaid only (03/2018)
Imipramine form Medicare only (11/2017)
Imlygic® forms Commercial & Medicaid (01/2018) or Medicare (01/2017)
Immune globulin (IVIG, SCIG) forms Commercial & Medicaid (03/2018) or Medicare (03/2018)
Immunosuppressive drugs (oral) form Medicare Part B vs. Part D determination (09/2017)
Impavido® form Commercial & Medicaid only (07/2017)
Increlex® forms Commercial (02/2018) or Medicaid (02/2018)
Inflectra™ forms Commercial and Medicaid (01/2018) or Medicare (01/2018)
Ingrezza® forms Commercial (01/2018) and Medicare (07/2017)
Inhalation solutions used with a nebulizer form Medicare Part B vs. Part D determination (09/2017)
Inlyta® forms Commercial (07/2017) or Medicare (07/2017)
Intrarosa™ form Commercial only (09/2017)
Invokamet®, Invokana® forms MyPriority® (01/2018) or Medicaid (02/2018)
Iressa® forms Commercial (09/2017) or Medicare (07/2017)
Istodax® form Commercial and Medicaid (04/2018)
IVIG forms Commercial and Medicaid (03/2018) or Medicare (03/2018)

J

Jakafi® forms Commercial & Medicaid (07/2017) or Medicare (07/2017)
Janumet®/Janumet XR®/Januvia®/Jentadueto® forms MyPriority (03/2017) or Medicaid (02/2018)
Jardiance® forms MyPriority (01/2018) or Medicaid (02/2018)
Jevtana® forms Commercial & Medicaid (11/2017) or Medicare (11/2016)
Juxtapid® forms Commercial (03/2017) or Medicare (01/2017)

K

Kadcyla forms Commercial & Medicaid (05/2017) or Medicare (05/2017)
Kalbitor® forms Commercial (01/2018) or Medicare (01/2017)
Kalydeco® forms Commercial (03/2018) or MyPriority (01/2018) or Medicare (01/2018)
Kanuma® form Commercial & Medicaid only (03/2018)
Keveyis® form Commercial only (11/2017)
Kevzara® forms Commercial (03/2018) or Medicare (03/2018)
Keytruda® forms Commercial & Medicaid (11/2017) or Medicare (11/2016)
Kineret® forms Commercial (03/2018) or Medicare (09/2016)
Kisqali® forms Commercial & Medicaid (05/2017) or Medicare (06/2017)
Kitabis Pak™ forms Commercial (02/2018) or Medicaid (02/2018) or Medicare (11/2016)
Kombiglyze® XR form MyPriority only (03/2017)
Korlym® form Commercial only (05/2017)
Krystexxa® form Commercial & Medicaid only (03/2018)
Kymriah™ form Commercial only (01/2018)
Kynamro® forms Commercial & Medicaid (05/2016) or Medicare (03/2018)

L

Lartruvo  Commercial and Medicaid only (03/2018)
Lazanda® forms Commercial (11/2017) or Medicare (11/2016)
Lemtrada® Medicare only (01/2017)
Lenvima® forms Commercial (07/2017) or Medicare (05/2017)
Letairis®  Commercial (02/2018) or Medicaid (02/2018)
Lidocaine 5% patch forms Commercial (11/2017) or Medicare (11/2017)
Linezolid
Commercial (02/2018) or Medicaid (02/2018)
Lonsurf®
 forms Commercial (11/2017) or Medicare (11/2017)
Lotronex®  Commercial only (10/2017)
Lovaza® Commercial (02/2018) or Medicaid (02/2018)
Lucentis®Commercial and Medicaid only (01/2018)
LuxturnaCommercial only (03/2018)
Lynparza® forms Commercial and Medicaid (03/2018) or Medicare (03/2017)

M

Macugen® Commercial & Medicaid only (01/2018)
Makena® Commercial & Medicaid only (05/2017)
Marqibo® Commercial & Medicaid only (11/2017)
Matulane® forms Commercial (07/2017) or Medicare (07/2017)
Mavyret™ forms Commercial group (11/2017) or MyPriority (11/2017) or Medicare (03/2018)
Mekinist® forms Commercial (09/2017) or Medicare (01/2017)
Methadone MyPriority only (09/2017)
Mirvaso® Medicare only (01/2018)
Modafinil form Medicare (03/2018)
Morphine MyPriority only (09/2017)
Myalept® forms Commercial (01/2018) or Medicare (01/2017)
Mylotarg®Commercial and Medicaid only (03/2018)
Myorisan Commercial only (05/2017)

N

Naglazyme® Commercial & Medicaid only (05/2017)
Naproxen suspension Medicaid only (04/2018)
Natpara® forms Commercial (07/2017) or Medicare (01/2018)
Nebupent® Medicare only (01/2018)
Nerlynx® forms Commercial (03/2018) or Medicare only (09/2017)
Neupogen® forms Medicaid (02/2018) or Medicare (09/2017)
Nexavar® forms Commercial (07/2017) or Medicare (07/2017)
Ninlaro® Commercial only (07/2016)
Nityr® Commercial only (11/2017)
Nplate® forms Commercial (07/2017) or Medicare (05/2017)
Nucala® forms Commercial (03/2018) or Medicare Part B (07/2017)
Nucynta® ER MyPriority only (04/2018)
Nuedexta® Commercial only (11/2017)
Nulojix® forms Commercial & Medicaid (11/2017) or Medicare (11/2016)
Nuplazid™ forms Commercial (07/2017) or Medicare (07/2017)
Nuvigil® forms Commercial (11/2017) 

O

OcalivaCommercial only (09/2017)
OcrevusCommercial and Medicaid only (01/2018)
Octreotide Medicaid only (02/2018)
Odomzo® Commercial only (11/2017)
Ofev® forms Commercial (01/2017) or Medicare (01/2017)
Ondansetron Medicare Part B vs. Part D determination (11/2017)
Onglyza® MyPriority only (03/2017)
Onivyde® forms Commercial & Medicaid (01/2018) or Medicare (01/2017)
Opdivo® forms Commercial & Medicaid (03/2018) or Medicare (09/2016)
Opioid drug exceptions Commercial & Medicaid only (11/2017)
Opsumit® forms Commercial (01/2017) or Medicare (01/2017)
Oral oncology drugs Medicaid only (02/2018)
Orencia® forms Commercial (03/2017) or Medicare (01/2018)
Orenitram® ER forms Commercial (05/2017) or Medicare (01/2018)
Orfadin® forms Commercial (03/2018) or Medicare (07/2017)
Orkambi® forms Commercial group (09/2017) or MyPriority (05/2017) or Medicare (09/2017)
Osphena®  Commercial only (05/2016)
Otezla® forms Commercial (03/2018) or Medicaid (02/2018) or Medicare (01/2017)
Oxtellar™ XR Commercial only (07/2017)
Oxycodone ER MyPriority only (09/2017)
OxyContin® MyPriority only (09/2017)
Oxymorphone ER MyPriority only (09/2017)

P

Parsabiv™  form Commercial only (01/2018)
Perjeta®
Commercial & Medicaid only (11/2017)
Phenobarbital Medicare only (01/2017)
Phenoxybenzamine Commercial only (04/2018)
Plegridy™  MyPriority only (05/2017)
Pomalyst forms Commercial & Medicaid (05/2017) or Medicare (01/2018)
Praluent® forms Commercial (03/2018)
Prevymis® Commercial only (03/2018)
Procrit® forms Medicaid (02/2018) or Medicare Part B vs. Part D determination (09/2017)
Prolastin®
 forms Commercial & Medicaid (03/2018) or Medicare (03/2018)
Prolia® forms Commercial & Medicaid (07/2017) or Medicare (01/2018)
Promacta® forms Commercial (11/2017) or Medicare (11/2017)
Promethazine Medicare only (01/2017)
Provenge® forms Commercial & Medicaid (11/2017) or Medicare (11/2016)
Pulmozyme® forms Commercial group (11/2017) or MyPriority (11/2017) or Medicaid (02/2018)

Q, R

Qtern® MyPriority only (01/2018)
Radicava® forms Commercial (09/2017) or Medicare (09/2017)
Ravicti®
 forms Commercial (01/2018) or Medicare (01/2017)
Ranexa® Medicaid only (02/2018)
Rayaldee® Medicare only (03/2018)
Rebif® MyPriority only (05/2017)
Relistor® injection forms Commercial (01/2018) or Medicare (11/2017)
Relistor® tablets Commercial only (01/2018)
Remicade® forms Commercial (01/2018) or Medicaid (01/2018) or Medicare (01/2018)
Remodulin® 
Commercial only (01/2018)
Renflexis™ forms Commercial & Medicaid (01/2018) or Medicare (03/2018)
Repatha® forms Commercial (03/2017)
Revlimid® forms Commercial (03/2018) or Medicare (03/2018)
Rituxan® forms Commercial & Medicaid (09/2017) or Medicare (09/2017)
Rituxan Hycela™ Commercial & Medicaid only (09/2017)
Rubraca® forms Commercial (03/2017) or Medicare (03/2017)
Ruconest® forms Commercial (01/2018) or Medicare (01/2017)
Rydapt® forms Commercial (07/2017) or Medicare (07/2017)

S

Sabril®  Commercial only (11/2017)
Samsca®
 forms Commercial (09/2017) or Medicare (09/2017)
Sancuso® Medicare only (05/2017)
Serostim® forms Commercial (05/2017) or Medicare (05/2017)
Signifor® forms Commercial (07/2016) or Medicare (07/2016)
Signifor LAR® Commercial only (07/2016)
Sildenafil 20 mg tablet forms Commercial (02/2018) or Medicaid (02/2018) or Medicare (03/2018)
Siliq® forms Commercial (03/2018) or Medicare (09/2017)
Simponi® and Simponi Aria® forms Commercial (03/2018) or Medicare (03/2018)
Sivextro® forms Commercial (03/2017) or Medicare (03/2017)
Smoking cessation products Commercial & Medicaid (11/2017)
Soliqua MyPriority only (03/2017)
Soliris® forms Commercial & Medicaid (03/2018) or Medicare (03/2017)
Somavert® Commercial only (01/2018)
Sovaldi® forms Commercial group (11/2017) or MyPriority (11/2017) or Medicare (01/2018)
Spinraza Commercial only (03/2017)
Sprycel® forms Commercial (01/2018) or Medicare (07/2017)
Stelara® forms Commercial (11/2017) or Medicare (03/2018)
Stimate® Medicaid only (04/2018)
Stivarga® forms Commercial (03/2018) or Medicare (03/2018)
Strensiq® Commercial only (01/2017)
Striant® forms Commercial (01/2017) or Medicare (01/2017)
Suboxone® forms MyPriority (09/2017) or Medicare (01/2017)
Subsys® forms Commercial (11/2017) or Medicare (11/2017)
Sumatriptan spray and injection Medicaid only (04/2018)
Supprelin LA® Commercial and Medicaid only (09/2017)
Surmontil® Medicare only (01/2017)
Sutent® forms Commercial (07/2017) or Medicare (07/2017)
Sylatron® forms Commercial (07/2017) or Medicare (07/2017)
Sylvant® forms Commercial & Medicaid (09/2017) or Medicare (09/2017)
Synagis® forms Commercial (02/2018) or Medicaid (02/2018)
Synjardy®/Synjardy® XR forms MyPriority (01/2018) or Medicaid (02/2018)
Synribo®  Medicare only (01/2017)
Syprine® Commercial only (03/2018)

T

Taflinar® forms Commercial (09/2017) or Medicare (01/2017)
Tagrisso® forms Commercial (01/2017) or Medicare (03/2018)
Taltz® forms Commercial (03/2018) or Medicare (03/2018)
Tanzeum® forms MyPriority (11/2017) or Medicaid (02/2018)
Tarceva® forms Commercial (03/2018) or Medicare (03/2018)
Targretin® forms Commercial (03/2018) or Medicare (07/2017)
Tasigna® forms Commercial (03/2018) or Medicare (03/2018)
Tecentriq® Commercial and Medicaid only (01/2018)
Tecfidera® forms MyPriority (07/2017) or Medicaid  (02/2018)
Technivie® forms Commercial group (11/2017) or MyPriority (11/2017)
Temozolomide Commercial (03/2018)
Testopel® Commercial only (11/2017)
Testosterone, topical forms Commercial (04/2017) or Medicare (03/2018)
Tetrabenazine Commercial only (03/2018)
Thalomid® forms Commercial (03/2017) or Medicare (07/2017)
Thiola® Commercial only (03/2018)
TOBI® Podhaler Commercial (02/2018) or Medicaid (02/2018)
Tobramycin Commercial (02/2018) or Medicaid (02/2018)
TofranilMedicare only (11/2017)
Torisel® Medicare only (11/2017)
Tracleer® forms Commercial (11/2017) or Medicaid (02/2018)
Tradjenta® forms MyPriority (03/2017) or Medicaid (02/2018)
Tramadol ER MyPriority only (09/2017)
Tremfya Commercial only (02/2018)
Tretinoin capsules forms Commercial (03/2018) or Medicare (03/2018)
Trientine form Commercial (04/2018)
Trulicity® MyPriority only (11/2017)
Tykerb® forms Commercial (03/2018) or Medicare (07/2017)
Tymlos® forms Commercial (07/2017) or Medicaid (04/2018) or Medicare (07/2017)
Tysabri® forms Commercial & Medicaid (03/2018) or Medicare (03/2018)
Tyvaso® forms Commercial (03/2018) or Medicare (01/2017)

U

Unituxin® Commercial and Medicaid only (07/2017)
Uptravi® Commercial and Medicaid (03/2018)

V

Valchlor® forms Commercial (01/2018) or Medicare (01/2017)
Valganciclovir Medicaid only (04/2018)
Vascepa® forms Commercial (01/2017) or Medicare (01/2017)
Vectibix® forms Commercial & Medicaid (09/2016) or Medicare (09/2016)
Velcade® Commercial & Medicaid only (03/2017)
Veletri® Commercial & Medicaid only (03/2018)
Vemlidy® Medicaid only (02/2018)
VenclextaCommercial (07/2017) or Medicare (01/2017)
Ventavis® forms Commercial (03/2017) or Medicare (07/2017)
Verzenio® forms Commercial (03/2018) or Medicare only (03/2018)
Vesanoid® forms Commercial (07/2017) or Medicare (07/2017)
Viberzi® Commercial only (09/2017)
Victoza® forms MyPriority (11/2017) or Medicaid (02/2018)
Viekira Pak® forms Commercial group (11/2017) or MyPriority (11/2017)
Vimizim® Commercial only (05/2017)
Vivlodex® Commercial only (03/2017)
Vosevi™ forms Commercial group (11/2017) or MyPriority (11/2017)
Votrient® forms Commercial (07/2017) or Medicare (07/2016)
Vpriv® Commercial & Medcaid only (05/2017)
Vyxeos® Commercial and Medicaid (03/2018)

W, X

Xalkori® forms Commercial (03/2017) or Medicare (07/2017)
Xarelto® form Medicaid only (02/2018)
Xatmep™ form Medicare only (03/2018)
Xeljanz® or Xeljanz XR® forms Commercial (02/2018) or Medicare (03/2018)
Xermelo™ Commercial only (05/2017)
Xgeva® Commercial & Medicaid only (03/2018)
Xiaflex® Commercial & Medicaid only (01/2017)
Xifaxan® Medicare only (01/2017)
Xigduo XR® MyPriority only (01/2018)
Xolair® forms Commercial & Medicaid (01/2018) or Medicare (01/2017)
Xtampza™ MyPriority only (09/2017)
Xtandi® forms Commercial & Medicaid (07/2017) or Medicare (07/2017)
Xultophy® MyPriority only (03/2017)
Xyrem® forms Commercial (03/2018) or Medicare (03/2018)

Y

Yervoy® forms Commercial & Medicaid (01/2017) or Medicare (07/2017)
YescartaCommercial only (03/2018)
Yondelis® forms Commercial & Medicaid (01/2018) or Medicare (01/2017)

Z

Zaleplon Medicare only (01/2018)
Zarxio® Medicaid only (02/2018)
Zejula® forms Commercial (07/2017) and Medicare (07/2017)
Zelboraf® forms Commercial (03/2018) or Medicare (03/2018)
Zemaira® forms Commercial & Medicaid (03/2018) or Medicare (03/2018)
Zenatane™ Commercial only (05/2017)
Zepatier™ forms Commercial group (11/2017) or MyPriority (11/2017) or Medicare (01/2018)
Zevalin®  Commercial & Medicaid only (11/2017)
Zinbryta™ MyPriority only (01/2017)
Zohydro ER® forms Commercial & Medicaid (11/2017) in addition, have the patient complete a Pain management agreement
Zolinza® forms Commercial & Medicaid (03/2018) or Medicare (03/2018)
Zolpidem/Zolpidem ER Medicare only (01/2018)
Zorbtive® Commercial only (09/2017)
Zubsolv® forms MyPriority (09/2017) or Medicare (11/2017)
Zydelig® forms Commercial (09/2016) or Medicare (09/2017)
Zykadia® forms Commercial (11/2017) or Medicare (11/2017)
Zytiga® forms Commercial & Medicaid (03/2018) or Medicare (01/2017)
Zyvox® forms Commercial (02/2018) or Medicaid (02/2018)