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Prior Authorizations
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2023 Prior Authorization

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.   

Acitretin

Actimmune

Adempas

Alpha1-Proteinase Inhibitors

Ambrisentan

Armodafinil

Austedo

Benlysta

Bexarotene Gel

Bosentan

Botulinum Toxins

CGRP Antagonists

Cinryze

Corticotropin Gel

Cystaran

Deferasirox

Dihydroergotamine Nasal Spray

Drizalma Sprinkle

Dronabinol

Dupixent

Enbrel

Endari

Epidiolex

ESRD

Fasenra

Fentanyl Citrate Transmucosal Lozenge

Filgrastim Agents

Fintepla

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

Icatibant

Ingrezza

Intravenous Immune Globulin (IVIG)

Kalydeco

Kerendia

Kesimpta

Korlym

Lidocaine Patches 

Lucemyra

Mavyret

Modafinil

Myalept

Natpara

Nayzilam

Norditropin

Nucala

Nuedexta

Ocaliva

Ofev

Opsumit

Oncology Agents: Oral

Orkambi

Otezla

Oxandrolone

Oxervate

Panretin

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

Pirfenidone

Posaconazole

Pregabalin ER

Promacta

Ravicti

Regranex

Repatha

Rezurock

Rinvoq

Sildenafil

Skyrizi

Sofosbuvir/velpatasvir

Sympazan

Tadalafil

Taltz

Teriparatide

Testosterone Products - Injectable

Testosterone Products - Topical

Tetrabenazine

Topical Retinoids

Uptravi

Valtoco

Voriconazole IV

Xeljanz

Xermelo

Xgeva

Xifaxan

Xolair

Xyrem

Xywav

Ztalmy