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Medication Prior Authorization Criteria

Effective March 1, 2019, Highmark Health Options will begin requiring prior authorization for antipsychotic medications for members younger than 18 years of age.
• Patients who are currently receiving antipsychotic therapy will be provided three months of provisional transition-in-care authorization.
• Patients who are new to antipsychotic therapy will require prior authorization upon initiation.
The new criteria and the prior authorization request form is here.
For questions regarding this notice, you may contact us at 1-844-325-6251.



Forms
General Drug Exception Form (Prior Authorization Form) Form
Home Infusion Form  Form


Name
Type
Acthar Pharmacy
Adcetris Medical & Pharmacy
Adult Stimulants (ADHD and Narcolepsy) Pharmacy
Alimta Medical & Pharmacy
Aloxi Medical & Pharmacy
Ampyra Pharmacy
Antidepressants Pediatric Pharmacy
Antipsychotics For Children Younger than 18 years old Pharmacy
Antiobesity drug Pharmacy
Atovaquone Pharmacy
Austedo and Ingrezza Pharmacy
Avastin Medical & Pharmacy
Benlysta Medical & Pharmacy
Bone Resorption Suppression and Related Agents Pharmacy
Botulinum Toxin (Botox) Medical & Pharmacy
Brineura  Medical & Pharmacy
Calcitonin Gene Related Peptide Receptor Inhibitors Pharmacy
Carisoprodol Pharmacy
Cerezyme Medical & Pharmacy
Chantix Pharmacy
Chimeric Antigen Receptor T cell (CAR-T) Immunotherapy Pharmacy
Cholinesterase Inhibitor Pharmacy
Chronic GI Motility Agents Pharmacy
Cimzia Pharmacy
Cinacalcet Pharmacy
Cough and Cold Medications for Children Less than 4 Years Pharmacy
Crysvita Medical & Pharmacy
Cystic Fibrosis Biologic Response Modifiers Pharmacy
Daraprim Pharmacy
Diacomit Pharmacy
Dutasteride Pharmacy
Emflaza Pharmacy
Enbrel Pharmacy
Epidiolex Pharmacy
Erbitux Medical & Pharmacy
Erythropoetin Stimulating Agents  Pharmacy
Exondys Medical & Pharmacy
Eylea Medical & Pharmacy
Fabry Disease Medications Pharmacy
Faslodex Medical & Pharmacy
Gralise Pharmacy
Granulocyte Colony-Stimulating Factors Medical & Pharmacy
Growth Hormone Pharmacy
Hemophilia/Blood Factor Products  Pharmacy
Hepatitis C Agents Pharmacy
Herceptin Medical & Pharmacy
Hereditary Angioedema (HAE) Agents Pharmacy
Humira Pharmacy
Inhaled LABA Corticosteroid Combination Medications Pharmacy
Intravenous Immunoglobulin (IVIG) and Subcutaneous Immunoglobulin (SCIG) Medical & Pharmacy
Intravenous Interleukin 5 Inhibitors Medical & Pharmacy
Isotretinoin Pharmacy
IV/Injectable Iron Medications Medical & Pharmacy
Keytruda Medical & Pharmacy
Krystexxa Medical & Pharmacy
Lidocaine Topical Patch Pharmacy
Lucemyra Pharmacy
Lucentis Medical & Pharmacy
Lumizyme Medical & Pharmacy
Lupron Medical & Pharmacy
Luxturna Medical & Pharmacy
Lyrica Pharmacy
Macugen Pharmacy
Makena (hydroxyprogesterone) Pharmacy
Megestrol Oxandrolone Pharmacy
Multiple Sclerosis Medications Medical & Pharmacy
Oncology Medications Medical & Pharmacy
Opioid Analgesics
-CDC Clinical Tools for Opioid Prescribing
Pharmacy
PCSK9 Inhibitor Therapy Pharmacy
Phenylketonuria Medications - Kuvan and Palynziq Pharmacy
Phosphorous Binders Pharmacy
Photofrin Medical & Pharmacy
Portrazza Medical & Pharmacy
Prialt Medical & Pharmacy
Provigil® (modafinil) and Nuvigil® (armodafinil) Pharmacy
Pulmonary Arterial Hypertension Pharmacy
Pulmozyme Pharmacy
Radicava Pharmacy
Regranex Pharmacy
Remicade Medical & Pharmacy
Restasis Pharmacy
Ocular Rho Kinase Inhibitors Pharmacy
Rituxan Medical & Pharmacy
Sandostatin LAR Medical & Pharmacy
Simponi Aria/Simponi Pharmacy
SGLT2 Inhibitors and Incretin Mimetics Pharmacy
Soliris Medical & Pharmacy
Somatuline Depot Medical & Pharmacy
Spinraza Medical & Pharmacy
Strensiq Pharmacy
Sublingual Immunotherapy Medications  Pharmacy
Sublocade Pharmacy
Supprelin/Vantas Medical & Pharmacy
Synagis Pharmacy
Synvisc and Synvisc-One (intra-articular hyaluronan injection) Pharmacy
Tavalisse Pharmacy
Testosterone Supplementation Pharmacy
Thrombopoietin (TPO) Receptor Agonists Pharmacy
Topical Immunomodulators Pharmacy
Transmucosal Immediate Release Fentanyl Formulations Pharmacy
Trogarzo Pharmacy
Tysabri Medical & Pharmacy
Vimizim Medical & Pharmacy
Visudyne Pharmacy
Vyvanse for Binge Eating Disorder Pharmacy
Weight Gain Promoting Agents Pharmacy
Xifaxan Pharmacy
Xolair Medical & Pharmacy
Xyrem Pharmacy
Yervoy Medical & Pharmacy
Zyvox linezolid Pharmacy
Qbrexa Pharmacy
Firdapse Pharmacy
Hyperkalemia Agents Pharmacy
Nuedextra Pharmacy
Non-TNF Biologic Therapies Medical & Pharmacy
Dupixent Pharmacy
Fentanyl transmucosal transbuccal Pharmacy
Freestyle Libre Pharmacy
Tobramycin Inhalation Products Pharmacy
Spravato Pharmacy
Compounds Pharmacy
Zulresso Pharmacy and Medical Policy
Evenity Pharmacy
Actimmune Pharmacy
Gattex Pharmacy
Zolgensma Pharmacy
Vyndamax and Vyndaqel Pharmacy
C5b Complement Inhibitors Pharmacy
Ravicti Pharmacy
Xiaflex Pharmacy
Duplicate Therapy Pharmacy

Need More Information?

Call Provider Services to learn more about our network and how to join at 1-844-325-6251.