Drug - Prior Authorization forms

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

Below are the Drug - Prior Authorization forms organized by drug name.

Drug - Prior Authorization forms

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• 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