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Medication Information

Prescription Drug Coverage
picture_as_pdfFormulary Updates
picture_as_pdfSpecialty Drug List
picture_as_pdfSpecialty Pharmacy List
MAC Price List
Drug Formulary
Drug Safety and Recall Information

Forms
picture_as_pdfGeneral Drug Exception Form (Prior Authorization Form | Use when one of the forms below do not apply)
picture_as_pdfHome Infusion Form

Prior Authorization Forms by Category and Name

Medical and Pharmacy Prior Authorization Forms
picture_as_pdfAloxi (Palonosetron)
picture_as_pdfAlpha1-Proteinase Inhibitors for Alpha-1 Antitrypsin Defciency (AAT)
picture_as_pdfAvastin
picture_as_pdfBenlysta
picture_as_pdfBotulinum Toxin (Botox)
picture_as_pdfBrineura
picture_as_pdfChimeric Antigen Receptor T-Cell (CAR-T) Immunotherapy
picture_as_pdfCidofovir
picture_as_pdfCrysvita
picture_as_pdfDuchenne Muscular Dystrophy Antisense Oligonucleotides (DMD AOs) (e.g., Viltepso, Vyondys53, Exondys51)
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., Nivestym, Ziextenzo, Fulphila, Granix, Neulasta, Neupogen, Udenyca, Zarixo)
picture_as_pdfHerceptin
picture_as_pdfImmune Globulin Products
picture_as_pdfIntravenous Interleukin 5 Inhibitors (IL-5) (e.g., Fasenra, Nucala, Cinqair)
picture_as_pdfIntravenous Injectable Iron
picture_as_pdfKrystexxa
picture_as_pdfLumizyme
picture_as_pdfLeuprolide Acetate Products (e.g., Lupron, Fensolvi)
picture_as_pdfLuxturna
picture_as_pdfMacular Degeneration Agents
picture_as_pdfMozobil
picture_as_pdfMultiple Sclerosis (MS) (e.g., Avonex, Aubagio, Mavenclad, Gilenya, Rebif)
picture_as_pdfNon-Formulary Medication (Medical Necessity)
picture_as_pdfNon-TNF Biologic Therapies (e.g., Orencia, Actemra, Cosentyx, Entyvio, Otezla, Taltz, Xeljanz)
picture_as_pdfPalforzia
picture_as_pdfPhotofrin
picture_as_pdfRemicade (Infliximab)
picture_as_pdfRituxan (Rituxumab)
picture_as_pdfSandostatin LAR
picture_as_pdfSomatuline Depot
picture_as_pdfSpinal Muscular Atrophy (SMA) (e.g., Spinraza, Zolgensma, Evrysdi)
picture_as_pdfSupprelin and Vantas
picture_as_pdfTepezza
picture_as_pdfTysabri
picture_as_pdfUplizna
picture_as_pdfXolair
picture_as_pdfZoladex
picture_as_pdfZulresso

Pharmacy Only Prior Authorization Forms
picture_as_pdfActhar
picture_as_pdfActimmune
picture_as_pdfAmpyra
picture_as_pdfAnti-Obesity Agents
picture_as_pdfAntipsychotics for Children 18 and Younger
picture_as_pdfAtovaquone
picture_as_pdfAustedo and Ingrezza
picture_as_pdfBone Resorption Suppression and Related Agents (e.g., Reclast, Aclasta, Prolia)
picture_as_pdfC5b Complement Inhibitors (e.g., Soliris, Ultomiris)
picture_as_pdfCalcitonin Gene Related Peptide Receptor Inhibitors (CGRPs) and Serotonin (5-HT) 1F Receptor (Migraine Agents)
picture_as_pdfCarisoprodol
picture_as_pdfCholinesterase Inhibitor for Alzheimer's Disease
picture_as_pdfChronic GI Motility Agents (e.g., Amitiza, Linzess, Trulance, Movantik, Relistor, Viberzi, Symproic, Motegrity)
picture_as_pdfCimzia
picture_as_pdfCinacalcet
picture_as_pdfCompounds
picture_as_pdfCough and Cold Medications for Children 4 and Younger
picture_as_pdfCOVID-19
picture_as_pdfCystic Fibrosis (CF) Biologic Response Modifiers (e.g., Trikafta, Symdeko, Orkambi, Kalydeco)
picture_as_pdfDaraprim
picture_as_pdfDiacomit
picture_as_pdfDupixent
picture_as_pdfDuplicate Therapy
picture_as_pdfDutasteride
picture_as_pdfEmflaza
picture_as_pdfEnbrel
picture_as_pdfEnspryng
picture_as_pdfEpidiolex
picture_as_pdfErythropoetin Stimulating Agents (ESA) (e.g., Aranesp, Epogen, Procrit, Retacrit, Mircera)
picture_as_pdfEvenity
picture_as_pdfFarxiga for Heart Failure
picture_as_pdfFirdapse
picture_as_pdfFreestyle Continuous Glucose Monitoring Systems
picture_as_pdfGattex
picture_as_pdfGralise
picture_as_pdfGrowth Hormone
picture_as_pdfHemophilia and Blood Factor Products
picture_as_pdfHepatitis C Agents (e.g., Mavyret, Sofosbuvir, Velpatasvit)
picture_as_pdfHereditary Angioedema (HAE) Agents (e.g., Cinryze, Takhzyro)
picture_as_pdfHumira
picture_as_pdfHyperkalemia Agents
picture_as_pdfInhaled LABA Corticosteroid Combination Medications (e.g., Advair, Symbicort, Dulera, Breo)
picture_as_pdfIsturisa
picture_as_pdfKoselugo
picture_as_pdfLatuda
picture_as_pdfLidocaine Topical Patch
picture_as_pdfLucemyra
picture_as_pdfLyrica
picture_as_pdfMakena (Hydroxyprogesterone)
picture_as_pdfMarinol (Dronabinol)
picture_as_pdfMegace (Megestrol)
picture_as_pdfMyalept
picture_as_pdfNuedextra
picture_as_pdfOcular Rho Kinase Inhibitors
picture_as_pdfOnpattro and Tegsedi
picture_as_pdfOpioid Analgesics
picture_as_pdfOpioid Analgesics (CDC Clinical Tools for Opioid Prescribing)
picture_as_pdfOral Isotretinoin
picture_as_pdfOriahnn
picture_as_pdfOrilissa
picture_as_pdfPCSK9 Inhibitor Therapy (e.g., Praluent, Repatha)
picture_as_pdf Phenylketonuria Medications (e.g., Kuvan and Palynziq)
picture_as_pdfPhosphorous 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_pdfQbrexa
picture_as_pdfRadicava
picture_as_pdfRavicti
picture_as_pdfRegranex
picture_as_pdfRestasis
picture_as_pdfSGLT2 Inhibitors and Incretin Mimetics (e.g., Invokana, Farxiga, Jardiance, Ozempic, Januvia, Tradjenta, Onglyza)
picture_as_pdfSickle Cell Agents
picture_as_pdfSimponi and Simponi Aria
picture_as_pdfSpravato
picture_as_pdfStimulants (Amphetamines for ADHD and Narcolepsy)
picture_as_pdfStrensiq
picture_as_pdfSublingual Immunotherapy Medications
picture_as_pdfSublocade
picture_as_pdfSubstance P Neurokinin-1 (NKI) Receptor Antagonists (e.g., Aaprepitant, Casopitant)
picture_as_pdfSynagis
picture_as_pdfSynvisc and Synvisc-One for Intra-Srticular Hyaluronan Injection
picture_as_pdfTavalisse
picture_as_pdfTestosterone Supplementation
picture_as_pdfThrombopoietin (TPO) Receptor Agonists (e.g., Doptelet, Mulpleta, Nplate, Promacta)
picture_as_pdfTobramycin Inhalation Products
picture_as_pdfTopical Immunomodulators (e.g., Protopic, Elidel, Eurcrisa)
picture_as_pdfTransmucosal Immediate Release Fentanyl Formulations (TIRF)
picture_as_pdfVyndamax and Vyndaqel
picture_as_pdfVyvanse for Binge Eating Disorder
picture_as_pdfXiaflex
picture_as_pdfXifaxan
picture_as_pdfXyrem
picture_as_pdfZyvox linezolid

Need More Information?

If you can not find the information you are looking for, call the Pharmacy Provider Services at 1-844-325-6251.