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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.

Dihydroergotamine Nasal Spray

Fentanyl Citrate Transmucosal Lozenge

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)

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

Sofosbuvir/velpatasvir

Testosterone Products - Injectable

Testosterone Products - Topical