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.
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Dihydroergotamine Nasal Spray (waiting for approval) Dronabinol (waiting for approval) Fentanyl Citrate Transmucosal Lozenge Forteo (waiting for approval) 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 Intravenous Immune Globulin (IVIG)
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Nucala (waiting for approval) 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: Oral Antiemetic Agents Part B vs D: Oral Chemotherapy/Immusuppresents Part B vs D: Parenteral Nutrition Testosterone Products - Injectable Testosterone Products - Topical Xeljanz (waiting for approval) |