Prescription Drug References for Members

  • Prescription Drug References for Members
  • Step Therapy Forms:
  • Mental Health Prior Authorization Request - (Antidepressants, Antipsychotics, Mental Health Diagnosis)
  • Antihistamine & Intranasal Steroid - (Clarinex, Clarinex D, Levocetirizine, Xyzal)
  • PPI & Cholesterol - (Aciphex, Dexilant, Nexium, Prevacid, Prilosec, Protonix, Zegerid)
  • Prior Authorization Forms for Drugs Covered Under Medicare Part D:
  • Alpha 1 Anti-trypsin Therapy - (Aralast, Glassia, Prolastin, Zemaira)
  • Amevive - (Amevive)
  • Anemia (Self Administration) - (Epogen, Procrit, and Aranesp)
  • Xenical Belviq Qsymia Contrave - (Xenical, Belviq, Qsymia and Contrave)
  • Xenical, Belviq, Belviq XR, Qsymia, New Start & Recertification - (Xenical, Belviq, Belviq XR, Qsymia)
  • Avastin - (Avastin)
  • Prolia - (Prolia)
  • Brand NSAIDs - (Arthrotec, Celebrex, Flector Patch, Ponstel)
  • Cimzia Crohn's (Health Professional Administered)
  • Cimzia Humira Crohns (Self Administered)
  • Cinryze (Health Professional Administered) - (applies to Cinryze)
  • Clinical Review Prior Authorization - (Arzerra, Ceprotin, Folotyn, Ilaris, Istodax, Kadcyla, Ocrevus, Provenge, Radicava, Soliris, Torisel)
  • Forteo, Tymlos - (Forteo, Tymlos)
  • Growth Hormone - (Omnitrope)
  • Hepatitis C - (Daklinza, Epclusa, Harvoni, Incivek, Mavyret, Olysio, PEG-Intron, Pegasys, Ribavirin, Sovaldi, Technivie, Victrelis, Viekira, Vosevi, Zepatier)
  • Hepatitis C Recertification - (Copegus, Infergen, PEG-Intron, Pegasys, Rebetol, Ribavirin)
  • Inborn Errors of Metabolism - (Aldurazyme, Carbaglu, Cerdelga, Cerezyme, Elaprase, Elelyso, Exondys 51, Fabrazyme, Kanuma, Lumizyme, Myozyme, Naglazyme, Orfadi, Spinraza, Sucraid, Vimizim, Vpriv, Xuriden, Zavesca)
  • IVIG & SCIG - (Bivigam, Carimune, Flebogamma, Gammagard, Gamunex, Gammaked, Hizentra, HyQvia, Octagan, Privigen)
  • Kuvan PKU - (Kuvan PKU)
  • Lupron - (Lupron)
  • Nplate - (Nplate)
  • Nuvigil/ Provigil - (Nuvigil, Provigil)
  • Orencia IV - (Orencia IV)
  • Promacta - (Promacta)
  • Provigil - (Provigil)
  • Psoriasis - (Cosentyx, Enbrel, Humira, Otezla)
  • Pulmonary Arterial Hypertension - (Adcirca, Letairis, Revatio, Tracleer, Tyvaso, Uptravi)
  • Remicade, Renflexis - (Remicade, Renflexis)
  • Rheumatoid Arthritis - (Actemra, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Simponi) Inflammatory Conditions (RA, PsA, AS) self-administered medications
  • Stelara (For Crohn's Disease) - (Stelara)
  • Synagis - (Synagis)
  • Tysabri Crohn's - (Tysabri Crohn's)
  • Tysabri Crohn's Recertification - (Tysabri Crohn's)
  • Tysabri MS - (Tysabri MS)
  • Xolair - (Xolair)
  • Zyvox (linezolid) & Sivextro (tedizolid phosphate) - Zyvox (linezolid) & Sivextro (tedizolid phosphate)
  • Prior authorization forms part d_copy
  • Additional Forms:
  • General Exception Request Form (Self Administered Drugs) - (used for requests that do not have a specific form below, or may be used to request an exception)
  • Quantity Limit Exception Form
Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. .
This page last updated .