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Prior Authorizations
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2021 Prior Authorizations

View the complete list of CMS-approved Prior Authorization criteria by plan by clicking on one of the links below:

 The following forms are downloadable in PDF format. 

Abilify MyCite

Actimmune

Adempas

Ambrisentan

Armodafinil

Austedo

Bosentan

Botulinum Toxins

CGRP Antagonists

Cinryze

Deferasirox

Dronabinol

Dupixent

Emflaza

Enbrel

Endari

Epidiolex

Esbriet

Fentanyl Citrate Transmucosal Lozenge

Filgrastim Agents

Fintepla

Forteo

Fotivda

Gattex

Gavreto

Hemady

H.P. Acthar Gel

Hetlioz

High Risk-General

High Risk-1st Generation Antihistamines

High Risk-Butalbital Combinations

High Risk-Sedative Hypnotics

High Risk-Non-Cox Selective NSAIDs

High Risk-Skeletal Muscle Relaxants

Hospice

Humira

Ingrezza

Intravenous Immune Globulin (IVIG)

Juxtapid

Kalydeco

Lidocaine Patches 

Long Acting Opioids

Lucemyra

Lyrica CR 

Mavenclad

Mavyret

Myalept

Nayzilam

Non-Formulary

Norditropin

Nucala 

 

Nuedexta

Ocaliva

Ofev

Onureg

Opsumit

Orgovyx

Orkambi

Oxervate

Part B vs D: ESRD

Part B vs D: Hep B Vaccine

Part B vs D: Infusion Pump Drugs

Part B vs D: Inhalation-Asthma/COPD

Part B vs D: Inhalation-Mucolytic

Part B vs D: Inhalation- Nebupent (pentamidine)

Part B vs D: Inhalation-Tobramycin

Part B vs D: Injectables

Part B vs D: Oral Antiemetic Agents

Part B vs D: Oral Chemotherapy/Immusuppresents

Part B vs D: Parenteral Nutrition

Pegfilgrastim Agents

Praluent

Promacta

Qinlock

Ravicti

Regranex

Repatha

Retevmo

Rinvoq

Sildenafil

Skyrizi

Sofosbuvir/velpatasvir

Stelara

Sympazan

Tabrecta

Tadalafil

Taltz

Targretin Gel

Tepmetko

Testosterone Products

Tetrabenazine

Thalomid

Topical Retinoids

Ukoniq

Uptravi

Valtoco

Vitrakvi

Xeljanz

Xgeva

Xifaxan

Xolair

Xospata

Xpovio

Xyrem