Special Authority drug list

This table lists the drugs that require SA approval. Click the drug name to see SA criteria and form(s).

Read up on faster, easier SA requests and approvals through eForms.

Links: About Special Authority | Limited coverage drugs | Insulin pumps | Continuous glucose monitors (CGMs) |​ SA request forms by condition 

This table can be sorted by using the arrow icons.
Generic Drug Name Brand Drug Name Automatic approval through eForms
abatacept for polyarticular juvenile idiopathic arthritis Orencia®  
abatacept for rheumatoid arthritis Orencia®  
abobotulinumtoxinA Dysport Therapeutic™  
acamprosate Campral®  
acetaminophen 500 mg Tylenol 500 mg®  
aclidinium Tudorza™ Genuair™  
aclidinium-formoterol Duaklir™ Genuair®  
adalimumab Amgevita®, Hadlima®, Hulio®, Humira®, Hyrimoz®, Idacio®  
alemtuzumab Lemtrada®  
alendronate 10/70 mg Fosamax® 10 mg / 70 mg  
alendronate with vitamin D 10/70 mg Fosavance® 70 mg / 5600 IU  
alendronate 40 mg Fosamax® 40 mg  
alitretinoin Toctino®  
ambrisentan Volibris®  
apixaban for atrial fibrillation Eliquis®  
apixaban for the treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) Eliquis® Yes
apixaban for venous thromboembolism Eliquis®  
apomorphine Movapo™, Kynmobi®  
aprepitant Emend®  
aripiprazole (Plan G) Abilify®  
aripiprazole monohydrate Abilify Maintena®  
asenapine Saphris™  
atomoxetine Strattera®  
aztreonam Cayston™  
baclofen intrathecal Lioresal® Intrathecal  
benazepril  (RDP - ACE Inhibitor Drugs) Lotensin®  
benzydamine Tantum®  
benralizumab Fasenra®  
bosentan Tracleer®  
botulinum neurotoxin type A, free from complexing proteins, also known as incobotulinumtoxinA Xeomin®  
botulinum neurotoxin type A, with complexing proteins, also known as onabotulinumtoxinA Botox®  
brexpiprazole (Plan G) Rexulti®  
brivaracetam Brivlera®  
budesonide capsules Entocort Capsules®  
budesonide enema Entocort Enema®  
budesonide-formoterol Symbicort®  
budesonide nebules Pulmicort®  
buprenorphine Sublocade™  
bupropion (Plan G) Wellbutrin® SR and XL, Zyban® Yes
candesartan Atacand®, Atacand Plus® Yes
captopril (RDP - ACE Inhibitor Drugs) Capoten®  
carvedilol Coreg® Yes
celecoxib Celebrex®  
certolizumab for the treatment of ankylosing spondylitis Cimzia®  
certolizumab for the treatment of psoriatic arthritis Cimzia®  
certolizumab for the treatment of rheumatoid arthritis Cimzia®  
chlorambucil Leukeran®  
chloroquine Aralen®  
ciclopirox 1% Loprox®  
cilazapril with/without HCTZ (RDP - ACE Inhibitor Drugs) Inhibace®, Inhibace Plus®  
cimetidine - prescription strength (RDP - H2 Blocker Drugs) Tagamet®  
ciprofloxacin ophthalmic Ciloxan®  
cladribine Mavenclad®  
clioquinol topical Locacorten Vioform, Vioform Hydrocortisone  
clobazam (Plan G) Frisium®  
clotrimazole Canesten Topical®  
codeine sustained release Codeine Contin®  
continuous glucose monitor Dexcom G6®  
cyclosporine Neoral®  
cyproterone (Plan G) Androcur®  
cysteamine ophthalmic solution Cystadrops®  
dabigatran Pradaxa®  
dalteparin Fragmin®  
dapagliflozin Forxiga® Yes
deferasirox Exjade®  
deferiprone Ferriprox®  
denosumab Prolia®  
desmopressin oral DDAVP Tablets®, DDAVP Melt®  
dextroamphetamine-amphetamine Adderall XR®  
diclofenac IR/SR Voltaren®, Arthrotec®  
diclofenac IR with misoprostol Arthrotec®  
dienogest Visanne®  
diflunisal Dolobid®  
dimethyl fumarate Tecfidera™  
diphenoxylate HCI-atropine sulfate Lomotil®  
dipyridamole-acetylsalicylic acid Aggrenox®   
donepezil Aricept®  
dorzolamide-timolol preservative free Cosopt non-preserved®  
dronedarone Multaq®  
duloxetine generics  
dutasteride Avodart®  
edaravone Radicava™  
empagliflozin and empagliflozin-metformin Jardiance®, Synjardy®  
enalapril without HCTZ (RDP - ACE Inhibitor Drugs) Vasotec®  
enalapril with HCTZ (RDP - ACE Inhibitor Drugs) Vasotec Plus®  
enoxaparin Inclunox®, Inclunox® HP, Noromby®, Noromby® HP, Redesca®, Redesca® HP  
entacapone Comtan®  
entacapone/levodopa/carbidopa combination tablet Stalevo®  
entecavir Baraclude®  
epoprostenol Caripul®, Flolan®  
eprosartan with/without HCTZ (RDP - ARB Drugs and LCD) Teventen®, Teveten Plus®  
eslicarbazepine acetate Aptiom™  
esomeprazole (RDP - PPI Drugs and LCD) Nexium®  
estradiol patches Climara®, Estalis®, Estalis-Sequi®, Estracomb®, Estraderm®, Estradot®, Oesclim®, Vivelle®  
estradiol transdermal gel Divigel®, Estrogel®  
etanercept Enbrel®, Brenzys™, Erelzi™  
evolocumab Repatha™  
ezetimibe Ezetrol®, generics  
famotidine (RDP - H2 Blocker Drugs) Pepcid®  
febuxostat Uloric®  
felodipine (RDP - Calcium Channel Blockers) Plendil®, Renedil®  
fentanyl patch Duragesic®  
fentanyl tablet Fentora®  
fidaxomicin Dificid®  
filgrastim Grastofil®, Nivestym®  
finasteride Proscar®  
fingolimod generics, Gilenya® (partial benefit)  
fluconazole oral solids Diflucan®  
flurbiprofen Ansaid®, Froben®  
fluticasone furoate-umeclidinium-vilanterol Trelegy® Ellipta®  
fluticasone furoate-vilanterol Breo® Ellipta®  
fluticasone propionate-salmeterol Advair®  
fluvastatin (RDP - Statin Drugs) Lescol®  
formoterol Foradil®, Oxeze® Turbuhaler®  
fosinopril (RDP - ACE Inhibitor Drugs) Monopril®  
fremanezumab Ajovy®  
gabapentin (Plan G) Neurontin®  
galantamine Reminyl®  
glatiramer acetate Glatect™, Copaxone®  
glecaprevir-pibrentasvir Maviret™  
gliclazide Diamicron® Yes
glycopyrronium Seebri® Breezhaler®  
golimumab Simponi®  
goserelin Zoladex®  
granisetron Kytril®  
glycerol phenylbutyrate Ravicti®  
glycopyrronium-indacaterol Ultibro® Breezhaler®  
hydromorphone controlled release Hydromorph Contin®  
hydromorphone injection Hydromorphone HP 50  
hydroxyurea Hydrea®  
hydroxyzine (Plan G) Atarax®  
icatibant Firazyr®  
indacaterol Onbrez® Breezhaler®  
indacaterol-glycopyrronium-mometasone furoate Enerzair® Breezhaler®  
indacaterol-mometasone furoate Atectura® Breezhaler®  
indapamide Lozide®  
indomethacin Indocid®  
infliximab Avsola®, Inflectra™, Renflexis™, Remicade®  
insulin detemir Levemir®, Levemir® FlexTouch®  
insulin glargine Basaglar™  
interferon alfa Intron A®  
interferon beta-1a Avonex®, Rebif®  
interferon beta-1b Betaseron®, Extavia®  
ipratropium nebules Atrovent®  
ipratropium and salbutamol combination nebules Combivent® UDV  
irbesartan with/without HCTZ (RDP - ARB Drugs and LCD) Avapro®, Avalide®  
iron isomaltoside Monoferric®  
iron sucrose Venofer®  
isavuconazole Cresemba®  
itraconazole Sporanox®  
ivabradine Lancora™  
ixekizumab Taltz™  
ketoconazole 2% cream Nizoral®  
ketoprofen enteric-coated Orudis E®  
ketoprofen SR Orudis®  
lacosamide tablets Vimpat®  
lactulose Laxilose®  
lamivudine Heptovir®  
lansoprazole 15 mg or 30 mg (RDP - PPI Drugs and LCD) Prevacid®  
ledipasvir-sofosbuvir Harvoni™  
letermovir Prevymis™  
leuprolide (Plan G) Lupron®  
levetiracetam Keppra®  
levodopa-carbidopa Duodopa®  
linagliptin and linagliptin-metformin Trajenta™, Jentadueto™  
linezolid 600 mg tablet Zyvoxam®  
lisdexamfetamine Vyvanse®  
lisinopril with or without HCTZ (RDP - ACE Inhibitor Drugs) Prinivil®, Zestril®, Zestoretic®  
loperamide Imodium®  
losartan Cozaar®, Hyzaar® Yes
lovastatin (RDP - Statin Drugs) Mevacor®  
meloxicam Mobicox®  
mepolizumab Nucala®  
mercaptopurine Purinethol®  
methotrexate pre-filled syringes PharmaScience  
methylphenidate extended-release Concerta®  
miconazole 2% topical Micatin Cream®  
miconazole topical Monistat Derm Cream®  
modafinil Alertec®  
mometasone-formoterol Zenhale™  
mometasone nasal spray Nasonex®  
mycophenolate mofetil CellCept®  
nabumetone Relafen®  
nadroparin Fraxiparine®  
naltrexone ReVia®  
naproxen enteric-coated (RDP - NSAIDs) Naprosyn EC®  
naproxen SR (RDP - NSAIDs) Naprosyn®  
natalizumab Tysabri®  
netupitant-palonosetron Akynzeo®  
nifedipine (RDP - Calcium Channel Blockers) Adalat®  
nintedanib Ofev®  
nirmatrelvir/ritonavir (Plan Z or ZE) Paxlovid® N/A
nitisinone Orfadin®  
nizatidine (RDP - H2 Blocker Drugs) Axid®  
obeticholic acid Ocaliva®  
ocrelizumab Ocrevus®  
ocriplasmin Jetrea®  
ofloxacin ophthalmic drops Ocuflox®  
olanzapine (Plan G) Zyprexa®, Zyprexa Zydis®  
olmesartan Olmetec®, Olmetec Plus®  
oseltamivir Tamiflu®  
omeprazole 20 mg (RDP - PPI Drugs and LCD) Losec® 20 mg  
ondansetron Zofran®  
paliperidone palmitate injection (Plan G) Invenga Sustenna®, Invega Trinza®  
pamidronate Aredia®  
pantoprazole magnesium RDP - PPI Drugs and LCD Tecta® Yes
pantoprazole sodium 40 mg (RDP - PPI Drugs and LCD) Pantoloc® 40 mg  
pentazocine Talwin®  
perampanel Fycompa™  
perindopril (RDP - ACE Inhibitor Drugs) Coversyl®  
pimecrolimus cream Elidel® Cream  
pioglitazone Actos®  
pirfenidone Esbriet®  
piroxicam capsule Feldene®  
pramipexole Mirapex®  
pravastatin (RDP - Statin Drugs) Pravachol®  
propranolol hydrochloride Hemangiol®  
prostaglandin compounded injection Prostaglandin®  
quinapril with HCTZ (RDP - ACE Inhibitor Drugs) Accuretic®  
rabeprazole (RDP - PPI DrugsLCD) Pariet® Yes
raloxifene Evista®  
ribavirin Ibavyr™  
rifaximin Zaxine®  
risedronate 30 mg Actonel® 30 mg  
risedronate 5/35 mg Actonel® 5 / 35 mg  
risperidone microspheres Risperdal Consta®  
rituximab Rituxan®, Truxima™, Riximyo and Ruxience  
risankizumab Skyrizi™  
rivaroxaban for atrial fibrillation Xarelto®  
rivaroxaban for concomitant coronary artery disease and peripheral artery disease Xarelto®  
rivaroxaban for prophylaxis of venous thromboembolism Xarelto®  
rivaroxaban for the treatment of venous thromboembolic events (DVT or PE) Xarelto® Yes
rivastigmine Exelon®  
ropinirole ReQuip®  
rotigotine Neupro®  
rufinamide Banzel®  
sacubitril-valsartan Entresto  
salbutamol nebules Ventolin®  
salmeterol Serevent®  
sarilumab Kevzara®  
saxagliptin and saxagliptin-metformin Onglyza®, Komboglyze™  
secukinumab Cosentyx®  
selexipag Uptravi®  
semaglutide Ozempic®  
sildenafil Viagra®  
simvastatin (RDP - Statin Drugs) Zocor®  
siponimod Mayzent®  
sodium cromoglycate nebules Intal® nebules  
sodium phenylbutyrate Pheburane®  
sofosbuvir Sovaldi®  
sofosbuvir-velpatasvir Epclusa®  
sofosbuvir-velpatasvir-voxilaprevir Vosevi™  
solifenacin generics only  
somatropin Genotropin®, Humatrope®, Norditriopin Nordiflex®, Nutropin AQ®, Omnitrope®, Saizen®  
stiripentol Diacomit™  
sulindac Clinoril®  
sumatriptan injection Imitrex® Injection  
supportive care for cancer treatment Grastofil(R) pre-filled syringe  
tacrolimus ointment Protopic® Ointment  
tadalafil 20 mg Adcirca®  
telmisartan without HCTZ (RDP - ARB Drugs and LCD) Micardis® Yes
telmisartan with HCTZ (RDP - ARB Drugs and LCD) Micardis Plus® Yes
telmisartan + amlodipine combination (RDP - ARB Drugs and LCD) Twynsta® Yes
tenofovir Viread®  
tenoxicam Mobiflex®  
terbinafine tablets Lamisil® tablets  
teriflunomide Aubagio™  
testosterone cypionate Depo-testosterone®  
testosterone enanthate Delatestryl®  
tiaprofenic acid regular release Surgam®  
ticagrelor Brilinta®  
ticlopidine Ticlid®  
tinzaparin Innohep®  
tiotropium Spiriva® Handihaler®  
tiotropium-olodaterol Inspiolto® Respimat®  
tizanidine Zanaflex®  
tobramycin Tobi®, Tobi® Podhaler®  
tocilizumab for the treatment of giant cell arteritis Actemra®  
tocilizumab for the treatment of active polyarticular juvenile idiopathic arthritis Actemra®  
tocilizumab for the treatment of active systemic juvenile idiopathic arthritis Actemra®  
tocilizumab for the treatment of rheumatoid arthritis Actemra®  
tofacitinib for the treatment of rheumatoid arthritis Xeljanz®  
tofacitinib for the treatment of ulcerative colitis Xeljanz®  
trandolapril (RDP - ACE Inhibitor Drugs) Mavik®  
treprostinil Remodulin®  
tretinoin topical Rejuva-A Cream®, Retin-A Cream®, Stieva-A Cream®, Vitamin A Acid Cream®  
trientine Mar-Trientine  
umeclidinium-vilanterol Anoro® Ellipta®  
ustekinumab Stelara®  
valganciclovir Valcyte®  
valsartan (RDP - ARB DrugsLCD) Diovan®, Diovan HCT® Yes
vancomycin oral Vancocin® Yes
varenicline (Plan G) Champix®  
vedolizumab Entyvio®  
voriconazole Vfend®  
vortioxetine Trintellix™  
zanamivir Relenza®  
ziprasidone (Plan G) Zeldox®  
zoledronic acid Aclasta™  
zopiclone (Plan G) Imovane®