Drug - Prior Authorization forms

Please be advised, commencing treatment without prior authorization does not guarantee continued coverage.

Below are the drugs that require prior authorization. To find the applicable form for any of the conditions or drugs listed below, please log on to Benefits Now® Plan Member.

Drug - Prior Authorization forms

 

  • A

  • Abraxane / Cancer
  • Actemra / Rheumatoid Arthritis
  • Adcetris
  • Adcirca / All Other
  • Adempas / All Other
  • Afinitor / Cancer
  • Agrylin / Cancer
  • Aimovig
  • Ajovy
  • Aldurazyme / All Other
  • Alecensaro / Cancer
  • Alimta / Cancer
  • Alunbrig / All Other
  • Alzenna / Cancer
  • Ambrisentan / All Other
  • Aptiom / All Other
  • Aptivus / All Other
  • Aranesp / All Other
  • Arixtra / All Other
  • Arsenic Trioxide / Cancer
  • Atgam / All Other
  • Atriance / Cancer
  • Aubagio / Multiple Sclerosis
  • Avastin / Cancer
  • Avonex / Multiple Sclerosis
  • Avsola / Ankylosing Spondylitis
  • Avsola / Inflammatory Bowel Disease
  • Avsola / Psoriatic arthritis
  • Avsola / Rheumatoid Arthritis
  • Avsola / Severe psoriasis

  • B

  • Banzel / All Other
  • Benlysta / All Other
  • Besponsa / Cancer
  • Betaseron / Multiple Sclerosis
  • Bosentan / All Other
  • Bosulif / Cancer
  • Botox / Chronic Migraine
  • Botox / Specialty Drug
  • Brenzys / Rheumatoid Arthritis
  • Brenzys / Ankylosing Spondylitis
  • Brenzys / Psoriatic Arthritis
  • Brenzys / Severe Psoriasis
  • Brenzys / Juvenile Idopathic Arthritis
  • Brilinta / All Other
  • Butorphanol / All Other

  • C

  • Cabazitaxel / Cancer
  • Cablivi
  • Cabometyx / Cancer
  • Caelyx / Cancer
  • Calquence / All Other
  • Caprelsa / Cancer
  • Carbaglu / All Other
  • Caripul / All Other
  • Cayston / All Other
  • Celsentri / All Other
  • Cerezyme / All Other
  • Cimzia / Ankylosing Spondylitis
  • Cimzia / Rheumatoid Arthritis
  • Cimzia / Psoriatic Arthritis
  • Cimzia / Severe Psoriasis
  • Cinacalcet
  • Cinqair / Severe Asthma
  • Clolar / Cancer
  • Contrave - plans with Anti-Obesity coverage
  • Copaxone / Multiple Sclerosis
  • 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

  • Dasatinib / Cancer
  • Daxas / All Other
  • Deferasirox / All Other
  • Diacomit / All Other
  • Dificid / All Other
  • Doxorubicin
  • Duodopa / All Other
  • Dupixent
  • Dysport

  • E

  • Egrifta / All Other
  • Elaprase / All Other
  • Elelyso / All Other
  • Eliquis / All Other
  • Emgality / All Other
  • Enbrel / Rheumatoid Arthritis
  • Enbrel / Psoriatic Arthritis
  • Enbrel / Ankylosing Spondylitis
  • Enbrel / Severe Psoriasis
  • Enbrel / Juvenile Idiopathic Arthritis
  • Entyvio / Crohn's Disease
  • Envarsus / All Other
  • Epclusa / Hepatitis C
  • Eprex / All Other
  • Erbitux / Cancer
  • Erelzi / Ankylosing Spondylitis
  • Erelzi / Juvenile Idiopathic Arthritis
  • Erelzi / Rheumatoid Arthritis
  • Erelzi / Psoriatic Arthritis
  • Erelzi / Severe Psoriasis
  • Erivedge / Cancer
  • Erleada
  • Erlotinib / Cancer
  • Esbriet / All Other
  • Evenity / Osteoporosis
  • Everolimus / Cancer
  • 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
  • Folotyn / Cancer
  • Forteo / Osteoporosis
  • Fosrenol / All Other
  • Fragmin / All Other
  • Fraxiparine / All Other
  • Fulphila / Cancer
  • Fuzeon / All Other
  • Fycompa / All Other

  • G

  • Galafold / All Other
  • Gazyva / Cancer
  • Gefitinib / Cancer
  • Gilenya / Multiple Sclerosis
  • Giotrif / Cancer
  • Glatect / Multiple Sclerosis
  • Glatiramer acetate / Multiple Sclerosis
  • Gleevec / Cancer
  • Grastofil

  • H

  • Halaven / Cancer
  • Harvoni / Hepatitis C
  • Hepsera / All Other
  • Herceptin / Cancer
  • Hizentra / All Other
  • 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

  • I

  • Ibavyr / All Other
  • Ibrance / Cancer
  • Iclusig / Cancer
  • Idhifa / Cancer
  • Ilaris / All Other
  • Imatinib / Cancer
  • Imbruvica / Cancer
  • Imfinzi
  • Inqovi / Cancer
  • 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 / Cancer
  • Istodax / Cancer

  • J

  • Jadenu / All Other
  • Jakavi / Cancer
  • Jevtana / Cancer
  • Jinarc / All Other
  • Juxtapid / High Cholesterol

  • K

  • Kadcyla / Cancer
  • Kalydeco / All Other
  • Kanjinti / Cancer
  • Kevzara
  • Keytruda / Cancer
  • Kineret / Rheumatoid Arthritis
  • Kisqali / Cancer
  • Kuvan / All Other
  • Kyprolis / Cancer

  • L

  • Lapelga
  • 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
  • Matulane / Cancer
  • Mavenclad
  • Maviret
  • Mayzent
  • Mekinist / Cancer
  • Metoject / All Other
  • Miglustat / All Other
  • Movapo / All Other
  • Mozobil / All Other
  • Mvasi / Cancer
  • Mylotarg / Cancer
  • Myozyme / All Other

  • N

  • Naglazyme / All Other
  • Nerlynx / Cancer
  • Neulasta
  • Neupogen
  • Neupro / All Other
  • Nexavar / Cancer
  • Nimotop
  • Ninlaro / Cancer
  • Nitisinone / All Other
  • Nivestym
  • Nplate / All Other
  • Nucala / Severe Asthma
  • Nucala / All Other

  • O

  • Ocaliva
  • Ocrevus
  • 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
  • Orencia / Psoriatic Arthritis
  • Orfadin / All Other
  • Orgaran / All Other
  • Orkambi / All Other
  • Otezla / Psoriatic Arthritis
  • Otezla / Severe Psoriasis
  • Oxervate / All Other
  • Ozurdex / All Other

  • P

  • Perjeta / Cancer
  • Pheburane / All Other
  • Piqray
  • 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
  • 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
  • Renflexis / Ankylosing Spondylitis
  • Renvela / All Other
  • Repatha / High Cholesterol
  • Replagal / All Other
  • Resonium Calcium Powder / 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
  • Rozlytrek
  • Ruxience / Cancer
  • Ruxience / Rheumatoid Arthritis
  • Rydapt / Cancer

  • S

  • Samsca / All Other
  • Sandostatin LAR / All Other
  • Saphris / All Other
  • Sativex / All Other
  • Saxenda - plans with Anti-Obesity coverage
  • Sensipar / All Other
  • Signifor / All Other
  • Signifor Lar / All Other
  • Siliq
  • 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
  • Stivarga / Cancer
  • Strensiq / All Other
  • Sublocade / All Other
  • Sutent / Cancer
  • Sylvant / Cancer
  • Symdeko

  • T

  • Tafinlar / Cancer
  • Tagrisso / Cancer
  • Taltz / Severe Psoriasis
  • Taltz / Psoriatic Arthritis
  • Taltz / Ankylosing Spondylitis
  • Tarceva / Cancer
  • Tasigna / Cancer
  • Tecentriq / Cancer
  • Tecfidera / Multiple Sclerosis
  • Tegsedi
  • Temodal / Cancer
  • Temozolomide / Cancer
  • Tepadina
  • Teriparatide
  • Thalomid / Cancer
  • 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 / Severe Psoriasis
  • Tremfya / Psoriatic Arthritis
  • Trisenox / Cancer
  • Truxima / Cancer
  • Truxima Rheumatoid / Arthritis
  • Tykerb / Cancer
  • Tysabri / Multiple Sclerosis

  • U

  • Uloric / All Other
  • Uptravi / Osteoporosis

  • V

  • Valcyte / All Other
  • Vascepa / Hypercholesterolemia
  • Vectibix / Cancer
  • Velcade / Cancer
  • Velphoro / All Other
  • Veltassa / All Other
  • Vemlidy / All Other
  • Venclexta / Cancer
  • Vesanoid / Cancer
  • Verzenio / Cancer
  • Vidaza / Cancer
  • Vimizim / All Other
  • Vizimpro / Cancer
  • Visudyne / All Other
  • Vitrakvi / Cancer
  • Vizimpro
  • Volibris / All Other
  • Vosevi / Hep C
  • Votrient / Cancer
  • Vpriv / All Other
  • Vyndaqel / All Other

  • X

  • Xalkori / Cancer
  • Xarelto / All Other
  • Xeljanz / Rheumatoid Arthritis
  • Xeljanz / Psoriatic Arthritis
  • Xeljanz / Crohn's Disease/Ulcerative Colitis
  • Xeloda / Cancer
  • Xenical-Plans with Anti-Obesity coverage / All Other
  • Xeomin / All Other
  • Xermelo / All Other
  • Xgeva / Cancer
  • 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
  • Zepatier / Hepatitis C
  • Ziextenzo
  • Zirabev / Cancer
  • Zoledronic Acid / Osteoporosis
  • Zoledronic Acid / Cancer
  • Zolinza / Cancer
  • Zydelig / Cancer
  • Zykadia / Cancer
  • Zytiga / Cancer
  • Zyvoxam / All Other