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Prescription Drug References for Practitioners
Prescription Drug References for Practitioners

You and your staff can request a coverage determination electronically, directly from your electronic medical record (EMR) or through CoverMyMeds ePA portal. Visit covermymeds.com for additional information on CoverMyMeds and electronic prior authorizations.

  • General Medications
  • Commercial 3-Tier Prior Authorization and Step Therapy Medication ListOpen a PDF
  • Medicaid Managed Care Prior Authorization and Step Therapy Medication ListOpen a PDF
  • Specialty Rx Medication List (Self-Administered Drugs) Open a PDF
  • Medical Specialty Drugs
  • Provider-Administered Medical Specialty Drugs Requiring Preauthorization-Commercial, Exchange, Medicare Managed Care membersOpen a PDF
  • Provider-Administered Medical Specialty Drugs Requiring Preauthorization-Medicaid Managed Care, Child Health Plus membersOpen a PDF
  • Drug Step Therapy Request Forms
  • Antihistamine & Intranasal SteroidOpen a PDF - (Clarinex, Clarinex D, Levocetirizine, Xyzal)
  • Mental Health Prior Authorization RequestOpen a PDF - (Antidepressants, Antipsychotics, Mental Health Diagnosis)
  • PPI & CholesterolOpen a PDF - (Aciphex, Dexilant, Nexium, Prevacid, Prilosec, Protonix, Zegerid)
  • Drug Exception Forms
  • General Exception Request Form (Self Administered Drugs)Open a PDF - (used for requests that do not have a specific form below, or may be used to request an exception)
  • Generic Advantage Program / MAC Penalty Exception Request Form Open a PDF
  • Medicare Age-Restricted BEERS List Exception FormOpen a PDF
  • Medicare D Chronic Insomnia - Request for Drug EvaluationOpen a PDF
  • Medicare D End Stage Renal Disease - Request for Drug EvaluationOpen a PDF
  • Medicare D Hospice - Request for Drug EvaluationOpen a PDF
  • Medicare D Lidocaine Patch & Flector Patch - Request for Drug EvaluationOpen a PDF
  • Medicare D Sulfonylurea - Request for Drug EvaluationOpen a PDF
  • Medicaid Managed Care Use Only
  • Standardized Prior Authorization FormOpen a PDF - For Medicaid Managed Care
  • Drug Prior Authorization Request Forms
  • Actemra IV (Health Professional Administered)Open a PDF
  • ActharOpen a PDF - (Acthar)
  • AliqopaOpen a PDF - (Aliqopa)
  • Alpha 1 Anti-trypsin TherapyOpen a PDF - (Aralast, Glassia, Prolastin, Zemaira)
  • Anemia (Self Administration)Open a PDF - (Epogen, Procrit, and Aranesp)
  • AvastinOpen a PDF - (Avastin)
  • Benlysta IVOpen a PDF - (Benlysta IV)
  • Benlysta SCOpen a PDF - (Benlysta SC)
  • Brand NSAIDsOpen a PDF - (Arthrotec, Celebrex, Flector Patch, Ponstel)
  • Cimzia Crohn's (Health Professional Administered)Open a PDF
  • Cimzia Humira Crohns (Self Administered)Open a PDF
  • Clinical Review Prior AuthorizationOpen a PDF - (Arzerra, Ceprotin, Folotyn, Ilaris, Istodax/Romidepsin, Kadcyla, Luxturna, Ocrevus, Provenge, Radicava, Soliris, Torisel)
  • Compounded Drug ProductsOpen a PDF
  • EgriftaOpen a PDF - (Egrifta)
  • Enteral Open a PDF - (Enteral)
  • EntyvioOpen a PDF - Entyvio
  • ESA (Erythropoiesis Stimulating Agents) For Medicare Part DOpen a PDF - (Aranesp, Epogen, Procrit)
  • Forteo,Tymlos Open a PDF - Forteo,Tymlos
  • GilenyaOpen a PDF - (Gilenya)
  • Growth HormoneOpen a PDF - (Omnitrope)
  • HAE (Hereditary Angioedema) - Provider AdministeredOpen a PDF - (Berinert, Cinryze, Kalbitor, Ruconest)
  • HAE (Hereditary Angioedema) - Self AdministeredOpen a PDF - (Berinert, Cinryze, Firazyr and Rucones)
  • HalavenOpen a PDF - Halaven
  • Hepatitis COpen a PDF - (Daklinza, Epclusa, Harvoni, Incivek, Mavyret, Olysio, PEG-Intron, Pegasys, Ribavirin, Sovaldi, Technivie, Victrelis, Viekira, Vosevi, Zepatier)
  • Inborn Errors of MetabolismOpen a PDF - (Aldurazyme, Carbaglu, Cerdelga, Cerezyme, Elaprase, Elelyso, Exondys 51, Fabrazyme, Kanuma, Lumizyme, Mepsevii, Myozyme, Naglazyme, Orfadi, Spinraza, Sucraid, Vimizim, Vpriv, Xuriden, Zavesca)
  • InfertilityOpen a PDF - (Bravelle, Cetrotide, corionic gonadotropin, Fertinex, Ganirelix, Gonal-F, Lupron, Luveris, Menopur, Novarel, Ovidrel, Pregnyl)
  • IVIG & SCIGOpen a PDF - (Bivigam, Carimune, Flebogamma, Gammagard, Gamunex, Gammaked, Hizentra, HyQvia, Octagan, Privigen)
  • KalydecoOpen a PDF - (Kalydeco)
  • KorlymOpen a PDF - (Korlym)
  • KrystexxaOpen a PDF - (Krystexxa)
  • Kuvan PKUOpen a PDF - (Kuvan PKU)
  • LemtradaOpen a PDF - Lemtrada
  • MarqiboOpen a PDF - Marqibo
  • MozobilOpen a PDF - Mozobil
  • NplateOpen a PDF - (Nplate)
  • Interleukin-5 AntagonistsOpen a PDF - (Cinqair, Fasenra, Nucala)
  • Nulojix Open a PDF - (Nulojix)
  • Off-LabelOpen a PDF - (FDA Approved Drugs)
  • Oncology (Health Professional Administered)Open a PDF - (Adcetris, Aliqopa, Arzerra, Bavencio, Beleodaq, Besponsa, Blincyto, Cyramza, Darzalex, Empliciti, Erwinaze, Folotyn, Gazyva, Halaven, Imfinzi, Istodax, Kadcyla, Keytruda, Kymriah, Kyprolis, Lartruvo, Mozobil, Mylotarg, Oncaspar, Onivyde, Opdivo, Portrazza, Provenge, Synribo, Tecentriq, Torisel, Vyxeos, Yervoy, Yescarta, Yondelis, Zaltrap)
  • Oncology (Self Administered)Open a PDF - Afinitor, Bosulif, Caprelsa, Cometriq, Erivedge, Gilotrif, Hycamtin, Iclusig, Imbruvica, Inlyta, Jakafi, Mekinist, Nexavar, Pomalyst, Revlimid, Signifor, Sprycel, Stivarga, Sutent, Sylatron Tafinlar, Tarceva, Tasigna, Tykerb, Valchlor, Votrient, Xalkori, Xtandi, Zelboraf, Zolinza, Zytiga
  • OnychomycosisOpen a PDF - Jublia, Kerydin, Onmel
  • Orencia IVOpen a PDF - (Orencia IV)
  • Orencia SQ Open a PDF - (Orencia SQ)
  • PCSK9 InhibitorsOpen a PDF - Praluent, Repatha
  • ProliaOpen a PDF - (Prolia)
  • PromactaOpen a PDF - (Promacta)
  • PsoriasisOpen a PDF - (Cosentyx, Enbrel, Humira, Otezla)
  • Pulmonary Arterial HypertensionOpen a PDF - (Adcirca, Letairis, Revatio, Tracleer, Tyvaso, Uptravi)
  • Pulmonary Arterial HypertensionOpen a PDF - (Flolan, Remodulin, Veletri, Ventavis)
  • Remicade, RenflexisOpen a PDF - (Remicade, Renflexis)
  • Rheumatoid ArthritisOpen a PDF - (Actemra, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Simponi) Inflammatory Conditions (RA, PsA, AS) self-administered medications
  • SabrilOpen a PDF - (Sabril)
  • Simponi AriaOpen a PDF - Simponi Aria
  • Stelara (For Crohn's Disease)Open a PDF - (Stelara)
  • Stelara (For Psoriasis or Psoriatic Arthritis)Open a PDF - (Stelara)
  • SynagisOpen a PDF - (Synagis)
  • TestosteroneOpen a PDF - Testosterone
  • Tysabri Crohn'sOpen a PDF - (Tysabri Crohn's)
  • Tysabri Crohn's RecertificationOpen a PDF - (Tysabri Crohn's)
  • Tysabri MSOpen a PDF - (Tysabri MS)
  • VectibixOpen a PDF - (Vectibix)
  • Xenical Belviq Qsymia ContraveOpen a PDF - (Xenical, Belviq, Qsymia and Contrave)
  • Xenical, Belviq, Belviq XR, Qsymia, New Start & Recertification Open a PDF - (Xenical, Belviq, Belviq XR, Qsymia)
  • XgevaOpen a PDF - (Xgeva)
  • XolairOpen a PDF - (Xolair)
  • ZaltrapOpen a PDF - Zaltrap
  • Zyvox (linezolid) & Sivextro (tedizolid phosphate) Open a PDF - Zyvox (linezolid) & Sivextro (tedizolid phosphate)