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Drug - Prior Authorization forms
Below are the Drug - Prior Authorization forms organized by drug name.
Drug - Prior Authorization forms
Enter text to search
A
Abraxane
/ Cancer
Abstral
/ All Other
Actemra
/ Rheumatoid Arthritis
Adcirca
/ All Other
Adempas
/ All Other
Afinitor
/ Cancer
Agrylin
/ Cancer
Aimovig
Aldurazyme
/ All Other
Alecensaro
/ Cancer
Alimta
/ Cancer
Alunbrig
/ All Other
Ambrisentan
/ All Other
Aptiom
/ All Other
Aptivus
/ All Other
Aranesp
/ All Other
Aredia
/ All Other
Arixtra
/ All Other
Arzerra
/ Cancer
Atgam
/ All Other
Atriance
/ Cancer
Aubagio
/ Multiple Sclerosis
Avastin
/ Cancer
Avonex
/ Multiple Sclerosis
B
Banzel
/ All Other
Benlysta
/ All Other
Besponza
/ Cancer
Betaseron
/ Multiple Sclerosis
Blenoxane
/ Cancer
Bosentan
/ All Other
Bosulif
/ Cancer
Botox
/ Chronic Migraine
Botox
/ Specialty Drug
Brenzys
/ Rheumatoid Arthritis
Brenzys
/ Ankylosing Spondylitis
Brilinta
/ All Other
Butorphanol
/ All Other
C
Cabometyx
/ Cancer
Caelyx
/ Cancer
Calquence
/ All Other
Camptosar
/ Cancer
Caprelsa
/ Cancer
Carbaglu
/ All Other
Caripul
/ All Other
Catena
/ All Other
Cayston
/ All Other
Celsentri
/ All Other
Cerezyme
/ All Other
Cimzia / Ankylosing Spondylitis
Cimzia
/ Rheumatoid Arthritis
Cimzia
/ Psoriatic Arthritis
Cinacalcet
Cinqair
/ Severe Asthma
Clolar
/ Cancer
Contrave - plans with Anti-Obesity coverage
Copaxone
/ Multiple Sclerosis
Cortiment
Cosentyx
/ Rheumatoid Arthritis
Cosentyx
/ Severe Psoriasis
Cosentyx
/ Psoriatic Arthritis
Cosentyx
/ Ankylosing Spondylitis
Cotellic
/ Cancer
Cresemba
Cuprimine
Cuvposa
Cyramza
/ Cancer
Cystadane
/ All Other
Cystadrops
/ All Other
Cytomel
/ All Other
D
Daklinza
/ Hepatitis C
Dasatinib
/ Cancer
Daxas
/ All Other
Deferasirox
/ All Other
Diacomit
/ All Other
Dificid
/ All Other
Duodopa
/ All Other
Dupixent
Dysport
E
Effient
/ All Other
Egrifta
/ All Other
Elaprase
/ All Other
Elelyso
/ All Other
Eliquis
/ All Other
Eloxatin
/ Cancer
Emgality
/ All Other
Enbrel
/ Rheumatoid Arthritis
Enbrel
/ Psoriatic Arthritis
Enbrel
/ Ankylosing Spondylitis
Enbrel
/ Severe Psoriasis
Enbrel
/ Juvenile Idiopathic Arthritis
Entocort
/ All Other
Entresto
/ All Other
Entyvio
/ Crohn's Disease
Epclusa
/ Hepatitis C
Eprex
/ All Other
Erbitux
/ Cancer
Erelzi
/ Ankylosing Spondylitis
Erelzi
/ Juvenile Idiopathic Arthritis
Erelzi
/ Rheumatoid Arthritis
Erivedge
/ Cancer
Erlotinib
/ Cancer
Esbriet
/ All Other
Evenity
/ Osteoporosis
Everolimus
/ Cancer
Evotaz
/ All Other
Exjade
/ All Other
Extavia
/ Multiple Sclerosis
Eylea
/ All Other
F
Fabrazyme
/ All Other
Fampyra
/ Multiple Sclerosis
Fasenra
Faslodex
/ Cancer
Fasturtec
/ All Other
Febuxostat
/ All Other
Ferriprox
/ All Other
Fingolimod
/ All Other
Firazyr
/ All Other
Flolan
/ All Other
Fludara
/ Cancer
Forteo
/ Osteoporosis
Fosrenol
/ All Other
Fragmin
/ All Other
Fraxiparine
/ All Other
Fuzeon
/ All Other
Fycompa
/ All Other
G
Galafold
/ All Other
Galexos
/ Hepatitis C
Gazyva
/ Cancer
Gemzar
/ Cancer
Gefitinib
/ Cancer
Gilenya
/ Multiple Sclerosis
Giotrif
/ Cancer
Glatect
/ Multiple Sclerosis
Glatiramer acetate
/ Multiple Sclerosis
Gleevec
/ Cancer
Grastofil / Cancer
H
Halaven
/ Cancer
Harvoni
/ Hepatitis C
Hepsera
/ All Other
Herceptin
/ Cancer
Hizentra
/ All Other
Holkira Pak
/ Hepatitis C
Humira
/ Rheumatoid Arthritis
Humira
/ Psoriatic Arthritis
Humira
/ Ankylosing Spondylitis
Humira
/ Crohn's Disease / Ulcerative Colitis
Humira
/ Severe Psoriasis
Humira
/ Hidradenitis Suppurativa
Humira
/ Uveitis
Humira
/ Juvenile Idiopathic Arthritis
Hycamtin
/ Cancer
I
Ibavyr
/ All Other
Ibrance
/ Cancer
Iclusig
/ Cancer
Idhifa
/ Cancer
Ilaris
/ All Other
Imatinib
/ Cancer
Imbruvica
/ Cancer
Imfinzi
Incivek
/ All Other
Inflectra
/ Crohn's Disease / Ulcerative Colitis
Inflectra
/ Rheumatoid Arthritis
Inflectra
/ Ankylosing Spondylitis
Inflectra
/ Psoriatic Arthritis
Inflectra
/ Severe Psoriasis
Inlyta
/ Cancer
Innohep
/ All Other
Intron A
/ Hepatitis C
Intron A
/ Cancer
Iressa
/ Cancer
Irinotecan for Injection
/ Cancer
Istodax
/ Cancer
J
Jadenu
/ All Other
Jakavi
/ Cancer
Jetrea
/ All Other
Jevtana
/ Cancer
Jinarc
/ All Other
Juxtapid
/ High Cholesterol
K
Kadcyla
/ Cancer
Kalydeco
/ All Other
Kepivance
/ All Other
Kevzara
Keytruda
/ Cancer
Kineret
/ Rheumatoid Arthritis
Kisqali
/ Cancer
Kuvan
/ All Other
Kyprolis
/ Cancer
L
Lapelga
/ Cancer
Lartruvo
/ Cancer
Lemtrada
/ Multiple Sclerosis
Lenvima
/ Cancer
Libtayo
/ Cancer
Lokelma
/ All Other
Lonsurf
/ Cancer
Lorbrena
/ Cancer
Lovenox
/ All Other
Lucentis
/ All Other
Lynparza
/ Cancer
Lysodren
/ Cancer
M
Mabcampath
/ Cancer
Macugen
/ All Other
Matulane
/ Cancer
Mavenclad
Maviret
Mekinist
/ Cancer
Metoject
/ All Other
Miglustat
/ All Other
Movapo
/ All Other
Mozobil
/ All Other
Mvasi
/ Cancer
Myozyme
/ All Other
N
Naglazyme
/ All Other
Nerlynx
/ Cancer
Neulasta / Cancer
Neupogen / Cancer
Neupro
/ All Other
Nexavar
/ Cancer
Nimotop
Ninlaro
/ Cancer
Nitisinone
/ All Other
Nplate
/ All Other
Nucala
/ Severe Asthma
Nucala
/ All Other
O
Ocaliva
Ocrevus
/ Multiple Sclerosis
Octostim
/ All Other
Ofev
/ All Other
Ogivri
/ Cancer
Olumiant
/ Rheumatoid Arthritis
Onstryv
/ All Other
Opdivo
/ Cancer
Opsumit
/ All Other
Orencia
/ Rheumatoid Arthritis
Orencia
/ Juvenile Idiopathic Arthritis
Orfadin
/ All Other
Orgaran
/ All Other
Orkambi
/ All Other
Otezla
/ Rheumatoid Arthritis
Otezla
/ Psoriatic Arthritis
Otezla
/ Severe Psoriasis
Oxervate
/ All Other
Ozurdex
/ All Other
P
Perjeta
/ Cancer
Pheburane
/ All Other
Plegridy
/ Multiple Sclerosis
Pomalyst
/ Cancer
Posanol
/ All Other
Pradaxa
/ All Other
Praluent
/ High Cholesterol
Prevymis
/ All Other
Procysbi
Prolastin
/ All Other
Pulmozyme
/ All Other
Q
Quinsair
R
Radicava
Ravicti
Rebif
/ Multiple Sclerosis
Regranex
/ All Other
Remicade
/ Rheumatoid Arthritis
Remicade
/ Psoriatic Arthritis
Remicade
/ Ankylosing Spondylitis
Remicade
/ Crohn's Disease / Ulcerative Colitis
Remicade
/ Severe Psoriasis
Remodulin
/ All Other
Renagel
/ All Other
Renflexis
/ Rheumatoid Arthritis
Renflexis
/ Crohn's Disease / Ulcerative Colitis
Renflexis
/ Psoriatic Arthritis
Renflexis
/ Severe Psoriasis
Renvela
/ All Other
Repatha
/ High Cholesterol
Replagal
/ All Other
Restasis
/ All Other
Revatio
/ All Other
Revestive
/ All Other
Revlimid
/ Cancer
Revolade
/ All Other
Rilutek
/ All Other
Riluzole
/ All Other
Rinvoq
/ Rheumatoid Arthritis
Rituxan
/ Cancer
Rituxan
/ Rheumatoid Arthritis
Rydapt
/ Cancer
S
Samsca
/ All Other
Sandostatin LAR
/ All Other
Saphris
/ All Other
Sativex
/ All Other
Saxenda - plans with Anti-Obesity coverage
Sebivo
/ All Other
Sensipar
/ All Other
Signifor
/ All Other
Signifor Lar
/ All Other
Siliq / Severe Psoriasis
Simulect
/ All Other
Skyrizi
/ Severe Psoriasis
Soliris
/ All Other
Somatuline
/ All Other
Simponi
/ Rheumatoid Arthritis
Simponi
/ Psoriatic Arthritis
Simponi
/ Ankylosing Spondylitis
Simponi
/ Non-radiographic Axial Spondyloarthritis
Simponi
/ Crohn's Disease / Ulcerative Colitis
Sovaldi
/ Hepatitis C
Sprycel
/ Cancer
Stelara
/ Severe Psoriasis
Stelara
/ Crohn's Disease / Ulcerative Colitis
Stelara
/ Psoriatic Arthritis
Stemgen
/ All Other
Stivarga
/ Cancer
Strensiq
/ All Other
Sunvepra
/ Hepatitis C
Sutent
/ Cancer
Sylvant
/ Cancer
Symdeko
T
Tafinlar
/ Cancer
Tagrisso
/ Cancer
Taltz
/ Severe Psoriasis
Taltz
/ Psoriatic Arthritis
Tarceva
/ Cancer
Tasigna
/ Cancer
Taxotere
/ Cancer
Tecfidera
/ Multiple Sclerosis
Technivie
/ Hepatitis C
Tegsedi
Temodal
/ Cancer
Temozolomide
/ Cancer
Tepadina
Thalomid
/ Cancer
Thelin
/ All Other
Thyrogen
/ All Other
Tobi
/ All Other
Tobi Podhaler
/ All Other
Tobramycin
/ All Other
Tomudex
/ Cancer
Torisel
/ Cancer
Tracleer
/ All Other
Trazimera
/ Cancer
Treanda
/ Cancer
Tremfya
Trisenox
/ Cancer
Truxima
/ Cancer
Tykerb
/ Cancer
Tysabri
/ Multiple Sclerosis
U
Uloric
/ All Other
Uptravi
/ Osteoporosis
V
Valcyte
/ All Other
Vectibix
/ Cancer
Velcade
/ Cancer
Velphoro
/ All Other
Veltassa
/ All Other
Vemlidy
/ All Other
Venclexta
/ Cancer
Vesanoid
/ Cancer
Verzenio
/ Cancer
Vfend
/ All Other
Victrelis
/ Hepatitis C
Victrelis Triple
/ Hepatitis C
Vidaza
/ Cancer
Vimizim
/ All Other
Visimpro
/ Cancer
Virazole
/ All Other
Visudyne
/ All Other
Vitrakvi
/ Cancer
Vizimpro
Volibris
/ All Other
Voriconazole
/ All Other
Vosevi
/ Hep C
Votrient
/ Cancer
Vpriv
/ All Other
Vumon
/ Cancer
X
Xalkori
/ Cancer
Xarelto
/ All Other
Xeljanz
/ Rheumatoid Arthritis
Xeloda
/ Cancer
Xenical-Plans with Anti-Obesity coverage
/ All Other
Xeomin
/ All Other
Xermelo
/ All Other
Xgeva
/ Cancer
Xiaflex
/ All Other
Xiidra
Xolair
/ Severe Asthma
Xolair
/ Chronic Idiopathic Urticaria
Xospata
Xtandi
/ Cancer
Xyrem
/ All Other
Y
Yervoy
/ All Other
Yondelis
/ Cancer
Z
Zavesca
/ All Other
Zaxine
/ All Other
Zelboraf
/ Cancer
Zejula
/ Cancer
Zenapax
/ All Other
Zepatier
/ Hepatitis C
Zirabev
/ Cancer
Zoledronic Acid
/ All Other
Zolinza
/ Cancer
Zydelig
/ Cancer
Zykadia
/ Cancer
Zytiga
/ Cancer
Zyvoxam
/ All Other
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