Special Authority Drug List

The table below lists the drugs that require SA approval. Click the drug name to see the SA criteria and form(s). Note: eForms for the new digital system will be coming in 2022.

Related resources: SA Request Forms | About Special Authority | Formulary Search

Looking for medical devices requiring SA approval? See: Insulin pumps | Continuous glucose monitors (CGMs)

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