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  3. Medication Information

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)
picture_as_pdfHome Infusion Form

Prior Authorization Criteria by Type (Medical & Pharmacy, Pharmacy)

Medical & Pharmacy
picture_as_pdfAloxi
picture_as_pdfAlpha1-Proteinase Inhibitors
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
picture_as_pdfFabry Disease Medications
picture_as_pdfGamifant
picture_as_pdfGauche Disease: Enzyme Replacement and Substrate Reduction Therapy
picture_as_pdfGivlaari
picture_as_pdfGranulocyte Colony-Stimulating Factors
picture_as_pdfHerceptin
picture_as_pdfImmune Globulin Products
picture_as_pdfIntravenous Interleukin 5 Inhibitors
picture_as_pdfIV/Injectable Iron Medications
picture_as_pdfKrystexxa
picture_as_pdfLumizyme
picture_as_pdfLupron
picture_as_pdfLuxturna
picture_as_pdfMacular Degeneration Agents
picture_as_pdfMozobil
picture_as_pdfMultiple Sclerosis Medications
picture_as_pdfNon-Formulary Medication/Medical Necessity
picture_as_pdfNon-TNF Biologic Therapies
picture_as_pdfPalforzia
picture_as_pdfPhotofrin
picture_as_pdfRemicade
picture_as_pdfRituxan
picture_as_pdfSandostatin LAR
picture_as_pdfSomatuline Depot
picture_as_pdfSpinal Muscular Atrophy (SMA) Medications
picture_as_pdfSupprelin/Vantas
picture_as_pdfTepezza
picture_as_pdfTysabri
picture_as_pdfUplizna
picture_as_pdfXolair
picture_as_pdfZoladex
picture_as_pdfZulresso

Pharmacy
picture_as_pdfActhar
picture_as_pdfActimmune
picture_as_pdfAmpyra
picture_as_pdfAntiobesity drug
picture_as_pdfAntipsychotics For Children Younger than 18 years old
picture_as_pdfAtovaquone
picture_as_pdfAustedo and Ingrezza
picture_as_pdfBone Resorption Suppression and Related Agents
picture_as_pdfC5b Complement Inhibitors (Soliris & Ultomiris)
picture_as_pdfCalcitonin Gene Related Peptide Receptor Inhibitors and Serotonin (5-HT)1F Receptor
picture_as_pdfCarisoprodol
picture_as_pdfCholinesterase Inhibitor
picture_as_pdfChronic GI Motility Agents
picture_as_pdfCimzia
picture_as_pdfCinacalcet
picture_as_pdfCompounds
picture_as_pdfCough and Cold Medications for Children Less than 4 Years
picture_as_pdfCOVID-19
picture_as_pdfCystic Fibrosis Biologic Response Modifiers
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
picture_as_pdfEvenity
picture_as_pdfFarxiga Heart Failure
picture_as_pdfFentanyl transmucosal transbuccal
picture_as_pdfFirdapse
picture_as_pdfFreestyle Continuous Glucose Monitoring Systems
picture_as_pdfGattex
picture_as_pdfGralise
picture_as_pdfGrowth Hormone
picture_as_pdfHemophilia/Blood Factor Products
picture_as_pdfHepatitis C Agents
picture_as_pdfHereditary Angioedema (HAE) Agents
picture_as_pdfHumira
picture_as_pdfHyperkalemia Agents
picture_as_pdfInhaled LABA Corticosteroid Combination Medications
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
picture_as_pdfPhenylketonuria Medications - Kuvan and Palynziq
picture_as_pdfPhosphorous Binders
picture_as_pdfProvigil® (modafinil) and Nuvigil® (armodafinil)
picture_as_pdfPulmonary Arterial Hypertension
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
picture_as_pdfSickle Celle Agents
picture_as_pdfSimponi Aria/Simponi
picture_as_pdfSpravato
picture_as_pdfStimulants (ADHD and Narcolepsy)
picture_as_pdfStrensiq
picture_as_pdfSublingual Immunotherapy Medications
picture_as_pdfSublocade
picture_as_pdfSubstance P Neurokinin-1 (NKI) Receptor Antagonists
picture_as_pdfSynagis
picture_as_pdfSynvisc and Synvisc-One (intra-articular hyaluronan injection)
picture_as_pdfTavalisse
picture_as_pdfTestosterone Supplementation
picture_as_pdfThrombopoietin (TPO) Receptor Agonists
picture_as_pdfTobramycin Inhalation Products
picture_as_pdfTopical Immunomodulators
picture_as_pdfTransmucosal Immediate Release Fentanyl Formulations
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 Highmark Health Options Pharmacy Department Provider Services at 1-844-325-6251.