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Medication Information

Medical and Pharmacy Prior Authorization Forms
Pharmacy Only Prior Authorization Forms
Additional Prior Authorization Resources
Medical Drug Management (MDM) 2022 Prior Authorization List
picture_as_pdfAuthorization Requirement List – Jan. 2023
Medical Drug Management (MDM) Expansions
picture_as_pdfAuthorization Requirements – Effective February 2022
picture_as_pdfAuthorization Requirements – Effective December 2022
picture_as_pdfAuthorization Requirements – Effective July 2022
picture_as_pdfAuthorization Requirements – Effective March 2022
picture_as_pdfAuthorization Requirements – Effective Jan. 2022
Prescription Drug Coverage
picture_as_pdfCovered Drugs for 90-Day Supply
Drug Formulary
Drug Safety and Recall Information
picture_as_pdfFormulary Updates
picture_as_pdfMAC Price List
picture_as_pdfSpecialty Drug List
picture_as_pdfSpecialty Pharmacy List

Pharmacy Prior Authorization with CoverMyMeds

CoverMyMeds helps patients get the medication they need to live healthy lives by streamlining the prior authorization (PA) process for providers and pharmacists. Start today by creating a free account, or logging in to your existing account at covermymeds.com.

Use the following form when none of the current prior authorization forms listed below apply:
picture_as_pdfGeneral Drug Exception Form Prior Authorization Form | Updated April 2022

Additional Prior Authorization Resources

picture_as_pdfNurtec ODT (rimegepant) for Migraine
picture_as_pdfCGRP Antagonists Aimovig (erenumab-aooe) and Ajovy (fremanezumab-vfrm) for Migraine
picture_as_pdfDupixent (duplimumab) for Eczema

Prior Authorization Forms

Type keyword in the search bar or scroll through the prior authorization forms listed below.

Medical and Pharmacy Prior Authorization Forms

picture_as_pdfSite of Care Request Form
picture_as_pdfAduhelm (Aducanumab-avwa)
picture_as_pdfAlpha1-Proteinase Inhibitors for Alpha-1 Antitrypsin Deficiency (AAT)
picture_as_pdfAsthma and Allergy Biologics
picture_as_pdfAvastin
picture_as_pdfBotulinum Toxins (e.g. Dysport, Xeomin)
picture_as_pdfBrineura
picture_as_pdfC5b Complement Inhibitors (e.g., Soliris, Ultomiris)
picture_as_pdfChimeric Antigen Receptor T-Cell (CAR-T) Immunotherapy
picture_as_pdfCrysvita
picture_as_pdfCytokine and CAM Antagonists (e.g. Enbrel, Humira, Taltz)
picture_as_pdfDuchenne Muscular Dystrophy Antisense Oligonucleotides (DMD AOs) (e.g., Viltepso, Vyondys 53, Exondys 51)
picture_as_pdfEnzyme Replacement Therapy (Pompe Disease)
picture_as_pdfEvkeeza (Evinacumab-dgnb)
picture_as_pdfFabry Disease Enzyme Replacement Therapy (ERT) Medications (e.g., Galafold, Fabrazyme, etc.)
picture_as_pdfGamifant
picture_as_pdfGaucher Disease: Enzyme Replacement Therapy (ERT) and Substrate Reduction Therapy (e.g., Cerezyme, VPRIV, Elelyso)
picture_as_pdfGivlaari
picture_as_pdfGranulocyte Colony-Stimulating Factors (GCSFs) (e.g., Fulphila, Leukine, Neulasta, Neupogen, Udenyca, Zarxio)
picture_as_pdfHerceptin
picture_as_pdfHome Infusion Request Form
picture_as_pdfImcivree (Setmelanotide)
picture_as_pdfImmune Globulin Products
picture_as_pdfIntra-Articular Hyaluronan Injections (e.g. Synvisc, Synvisc-One)
picture_as_pdfIntravenous/Injectable Iron
picture_as_pdfKrystexxa
picture_as_pdfLeuprolide Acetate Products (e.g., Lupron, Fensolvi)
picture_as_pdfLuxturna
picture_as_pdfMacular Degeneration Agents
picture_as_pdfMakena (Hydroxyprogesterone)
picture_as_pdfMultiple Sclerosis (MS) (e.g., Avonex, Aubagio, Mavenclad, Gilenya, Rebif)
picture_as_pdfNon-Formulary Medication (Medical Necessity)
picture_as_pdfOnpattro, Tegsedi, and Amvuttra
picture_as_pdfPalforzia
picture_as_pdfRituxan (Rituxumab)
picture_as_pdfSandostatin LAR
picture_as_pdfSkysona (elivaldogene, autotemcel)
picture_as_pdfSomatuline Depot
picture_as_pdfSpinal Muscular Atrophy Medications
picture_as_pdfSupprelin LA
picture_as_pdfSystemic Lupus Erythematosus (SLE) Agents
picture_as_pdfTepezza
picture_as_pdfTysabri
picture_as_pdfUplizna
picture_as_pdfXenpozyme (olipudase alfa-rpcp)
picture_as_pdfXiaflex
picture_as_pdfZeposia (Ozanimod)
picture_as_pdfZoladex
picture_as_pdfZulresso (brexanolone)

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Pharmacy Only Prior Authorization Forms

picture_as_pdfAmpyra
picture_as_pdfAnti-Obesity Agents
picture_as_pdfAntipsychotics for children under age 18
picture_as_pdfAustedo and Ingrezza
picture_as_pdfBylvay (odevixibat)
picture_as_pdfCalcitonin Gene Related Peptide Receptor Inhibitors (CGRPs) and Serotonin (5-HT) 1F Receptor (Migraine Agents)
picture_as_pdfCarisoprodol
picture_as_pdfCinacalcet
picture_as_pdfCompounds
picture_as_pdfContinuous Glucose Monitoring Systems
picture_as_pdfCorticotropin (H.P Acthar, Purified Cortrophin Gel)
picture_as_pdfCough and Cold Medications for Children
picture_as_pdfCystic Fibrosis (CF) Biologic Response Modifiers (e.g., Trikafta, Symdeko, Orkambi, Kalydeco)
picture_as_pdfDaraprim
picture_as_pdfDuplicate Therapy
picture_as_pdfEmflaza
picture_as_pdfEnspryng
picture_as_pdfErythropoetin Stimulating Agents (ESA) (e.g., Aranesp, Epogen, Procrit, Retacrit, Mircera)
picture_as_pdfFirdapse
picture_as_pdfGattex
picture_as_pdfGene Therapy Agents
picture_as_pdfGrowth Hormone
picture_as_pdfHemophilia and Blood Factor Products
picture_as_pdfHepatitis C Agents (e.g., Mavyret, sofosbuvir/velpatasvir)
picture_as_pdfHereditary Angioedema (HAE) Agents (e.g., Cinryze, Takhzyro)
picture_as_pdfHyperkalemia Agents
picture_as_pdfInhaled LABA Corticosteroid Combination Medications (e.g., Advair, Symbicort, Dulera, Breo)
picture_as_pdfInjectable Osteoporosis Medications (e.g., Aclasta, Reclast, Prolia)
picture_as_pdfIsturisa
picture_as_pdfLeqvio (Inclisiran)
picture_as_pdfLidocaine Topical Patch
picture_as_pdfLivmarli (maralixibat)
picture_as_pdfLucemyra
picture_as_pdfLyrica
picture_as_pdfMarinol (Dronabinol)
picture_as_pdfMyalept
picture_as_pdfNuedexta
picture_as_pdfOcular Rho Kinase Inhibitors
picture_as_pdfOpioid Analgesics
picture_as_pdfOpioid Analgesics (CDC Clinical Tools for Opioid Prescribing)
picture_as_pdfOral Isotretinoin
picture_as_pdfOriahnn and Myfembree
picture_as_pdfOrilissa
picture_as_pdfPCSK9 Inhibitor Therapy (e.g., Praluent, Repatha)
picture_as_pdfPhenylketonuria Medications (e.g., Kuvan and Palynziq)
picture_as_pdfPhosphate Binders (e.g., Sevelamer, Renagel, Phoslyra, Calcium Acetate)
picture_as_pdfProvigil (Modafinil) and Nuvigil (Armodafinil)
picture_as_pdfPulmonary Arterial Hypertension (PAH)
picture_as_pdfPulmozyme
picture_as_pdfQbrexza
picture_as_pdfRadicava
picture_as_pdfRavicti
picture_as_pdfRestasis
picture_as_pdfSickle Cell Agents
picture_as_pdfSpravato
picture_as_pdfStimulants (Amphetamines for ADHD and Narcolepsy)
picture_as_pdfStrensiq
picture_as_pdfSublingual Immunotherapy Medications
picture_as_pdfSynagis
picture_as_pdfTestosterone Supplementation
picture_as_pdfThrombopoietics (e.g. Doptelet, Mulpleta, Nplate, Promacta, Tavalisse)
picture_as_pdfTobramycin Inhalation Products
picture_as_pdfTopical Immunomodulators (e.g., Protopic, Elidel, Eucrisa)
picture_as_pdfVygart (efgartigimod alfa-fcab)
picture_as_pdfVyndamax and Vyndaqel
picture_as_pdfXifaxan
picture_as_pdfXywav and Xyrem (sodium oxybate)

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Need more information?

If you can't find the information you need here, call Pharmacy Services at 1-844-325-6251.