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Medication Information

Prescription Drug Coverage
Medical and Pharmacy Prior Authorization Forms
Pharmacy Only Prior Authorization Forms

Prescription Drug Coverage

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

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

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_pdfAduhelm (aducanumab-avwa)
picture_as_pdfAloxi (Palonosetron)
picture_as_pdfAlpha1-Proteinase Inhibitors for Alpha-1 Antitrypsin Defciency (AAT)
picture_as_pdfAvastin
picture_as_pdfBenlysta
picture_as_pdfBotulinum Toxins (e.g. Dysport, Xeomin)
picture_as_pdfBrineura
picture_as_pdfChimeric Antigen Receptor T-Cell (CAR-T) Immunotherapy
picture_as_pdfCidofovir
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, Vyondys53, Exondys51)
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., Nivestym, Ziextenzo, Fulphila, Granix, Neulasta, Neupogen, Udenyca, Zarixo)
picture_as_pdfHerceptin
picture_as_pdfHome Infusion Request
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_pdfPalforzia
picture_as_pdfPhotofrin
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

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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_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_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_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_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

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