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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 (coming soon)

Bosentan

Botulinum Toxins

CGRP Antagonists

Cinryze (pending CMS approval)

Deferasirox

Dronabinol

Dupixent (pending CMS approval)

Emflaza

Enbrel

Endari

Epidiolex (pending CMS approval)

Esbriet

Fentanyl Citrate Transmucosal Lozenge

Filgrastim Agents

Fintepla (pending CMS approval)

Forteo

Gattex

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 (coming soon)

Humira

Ingrezza

Intravenous Immune Globulin (IVIG) (pending CMS approval)

Juxtapid

Kalydeco

Lidocaine Patches 

Long Acting Opioids

Lucemyra

Lyrica CR 

Mavenclad (pending CMS Approval)

Mavyret

Myalept

Nayzilam

Norditropin

Nucala

Nuedexta

Ocaliva

Ofev (pending CMS approval)

Opsumit

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/Immusuppresentas

Part B vs D: Parenteral Nutrition

Pegfilgrastim Agents

Praluent

Promacta

Qinlock

Ravicti

Regranex

Repatha

Retevmo

Sildenafil

Skyrizi

Sofosbuvir/velpatasvir

Stelara (pending CMS approval)

Sympazan

Tabrecta

Tadalafil

Taltz

Targretin Gel

Testosterone Products

Tetrabenazine

Thalomid

Topical Retinoids

Uptravi

Valtoco

Vitrakvi

Xeljanz

Xgeva (pending CMS approval)

Xifaxan

Xolair

Xospata

Xpovio (pending CMS approval)

Xyrem