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Prior Authorizations
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2022 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

Acitretin

Acthar Gel

Actimmune

Adempas

Ambrisentan

Armodafinil

Austedo

Bosentan

Botulinum Toxins

CGRP Antagonists

Cinryze

Cystaran

Deferasirox

Dihydroergotamine Nasal Spray

Dronabinol

Dupixent

Emflaza

Enbrel

Endari

Epidiolex

Esbriet

ESRD

Fasenra

Fentanyl Citrate Transmucosal Lozenge

Filgrastim Agents

Fintepla

Forteo

Gattex

Harvoni

Hetlioz

High Risk-General

High Risk-Butalbital Combinations

High Risk-First Generation Antihistamines

High Risk-Non-Benzo Sedative Hypnotics

High Risk-Non-Cox Selective NSAIDs

High Risk-Skeletal Muscle Relaxants

Hospice

Humira

Ingrezza

Intravenous Immune Globulin (IVIG)

Juxtapid

Kalydeco

Kesimpta

Lidocaine Patches 

Lucemyra

Mavenclad

Mavyret

Myalept

Natpara

Nayzilam

Non-Formulary

Norditropin

Nucala

Nuedexta

Ocaliva

Ofev

Opsumit

Oncology Agents: Oral

Orkambi

Oxervate

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)

Panretin

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

Pregabalin ER

Promacta

Ravicti

Regranex

Repatha

Rinvoq

Sildenafil

Skyrizi

Sofosbuvir/velpatasvir

Stelara

Sympazan

Tadalafil

Taltz

Targretin Gel

Testosterone Products - Injectable

Testosterone Products - Topical

Tetrabenazine

Topical Retinoids

Uptravi

Valtoco

Voriconazole IV

Xeljanz

Xermelo

Xgeva

Xifaxan

Xolair

Xyrem