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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 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
  • Request for Step Therapy Evaluation Prior Authorization FormOpen a PDF
  • 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 - Actemra
  • ActharOpen a PDF - (Acthar)
  • Adcetris Open a PDF - (brentuximab)
  • AliqopaOpen a PDF - (Aliqopa)
  • Alpha-1 Antitrypsin Deficiency (AAT)PDFOpen a PDF - (Aralast NP, Glassia, Prolastin-C, Zemaira)
  • Anemia (Self-Administered)Open a PDF - (Aranasp, Epogen, Procrit)
  • Anorexiants (New Start & Recertification)Open a PDF - Belviq, Belviq XR, Contrave, Qsymia, Xenical
  • AvastinOpen a PDF - (Avastin)
  • Benlysta IVOpen a PDF - (Benlysta IV)
  • Benlysta SCOpen a PDF - (Benlysta SC)
  • Cimzia Humira Crohns (Self Administered)Open a PDF
  • Cimzia Open a PDF - (Single Vial Use, Health Professional Administered)
  • Clinical Review Prior Authorization (Medical) For Healthcare Professional Administration OnlyOpen a PDF - Benlysta IV, Ceprotin, Hydroxyprogesterone, Ilaris, Krystexxa, Lemtrada, Luxturna, NPlate, Nulojix, Ocrevus, Radicava, Signifor LAR, Soliris, Sylvant, Trogarzo
  • Clinical Review Prior Authorization (Rx) Open a PDF
  • 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)
  • Firmagon Open a PDF - (Previously Degarelix)
  • Forteo,Tymlos Open a PDF - Forteo,Tymlos
  • GilenyaOpen a PDF - (Gilenya)
  • Growth HormoneOpen a PDF
  • HAE (Hereditary Angioedema) - Provider AdministeredOpen a PDF - (Berinert, Cinryze, Kalbitor, Ruconest)
  • HAE (Hereditary Angioedema) - Self AdministeredOpen a PDF - (Berinert, Cinryze, Firazyr, Haegarda, Ruconest, Takhzyro)
  • HalavenOpen a PDF - Halaven
  • Hepatitis COpen a PDF - Daklinza, Epclusa, Harvoni, Olysio, Pegasys, PEG-Intron, Ribavirin, Sovaldi, Technivie, Viekira, Vosevi, Zepatier
  • IVIG & SCIGOpen a PDF - (Bivigam, Carimune, Flebogamma, Gammagard, Gamunex, Gammaked, Hizentra, HyQvia, Octagan, Privigen)
  • Inborn Errors of MetabolismOpen a PDF - (Aldurazyme, Carbaglu, Cerdelga, Cerezyme, Crysvita, Elaprase, Elelyso, Exondys 51, Fabrazyme, Kanuma, LumizymeMepsevii, Naglazyme, Orfadi, Palynziq, Spinraza, Sucraid, Vimizim, Vpriv, Xuriden, Zavesca)
  • InfertilityOpen a PDF - (Bravelle, Cetrotide, corionic gonadotropin, Fertinex, Ganirelix, Gonal-F, Lupron, Luveris, Menopur, Novarel, Ovidrel, Pregnyl)
  • Inflammatory ConditionsOpen a PDF - Cimzia, Cosentyx, Enbrel, Humira, Kineret, Simponi
  • (Infliximab) Remicade, (infliximab-abda) Renflexis Open a PDF - (Infliximab) Remicade, (infliximab-abda) Renflexis
  • Interleukin-5 AntagonistsOpen a PDF - (Cinqair, Fasenra, Nucala)
  • KalydecoOpen a PDF - (Kalydeco)
  • KorlymOpen a PDF - (Korlym)
  • KrystexxaOpen a PDF - (Krystexxa)
  • KuvanOpen a PDF - (PKU)
  • LemtradaOpen a PDF - Lemtrada
  • MarqiboOpen a PDF - Marqibo
  • MozobilOpen a PDF - Mozobil
  • NplateOpen a PDF
  • NSAIDs Open a PDF - Duexis (ibuprofen/famotidine), Fenoprofen tablets, Flector (diclofenac patch), Pennsaid (diclofenac 2% solution), Sprix (ketorolac/tromethamine nasal spray), Tivorbex (indomethacin), Vimovo (naproxen/esomeprazole), Vivlodex (meloxicam), Zipsor (diclofenac), Zorvolex (diclofenac)
  • 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
  • Opioid Prior Authorization Request Form for Drug and Morphine Milligram Equivalents ReviewsOpen a PDF
  • Orencia IVOpen a PDF - RA & JIA
  • Orencia SQ Open a PDF - (Orencia SQ)
  • PCSK9 InhibitorsOpen a PDF - Praluent, Repatha
  • ProliaOpen a PDF
  • PromactaOpen a PDF
  • PsoriasisOpen a PDF - (Cosentyx, Enbrel, Humira, Otezla)
  • Pulmonary Arterial HypertensionOpen a PDF - (Flolan, Remodulin, Veletri, Ventavis)
  • Pulmonary Arterial HypertensionOpen a PDF - (Flolan, Remodulin, Veletri, Ventavis)
  • Rituxan, Rituxan Hycela (Health Professional Administered)Open a PDF - (Rituxan, Rituxan Hycela For Medicaid Managed Care)
  • SabrilOpen a PDF
  • Simponi AriaOpen a PDF - Simponi Aria
  • Stelera Open a PDF - (For Crohn's Disease)
  • Stelara (For Psoriasis or Psoriatic Arthritis)Open a PDF - (Stelara)
  • SynagisOpen a PDF - Respiratory Syncytial Virus (RSV) Prophylaxis
  • TestosteroneOpen a PDF - Testosterone
  • TremfyaOpen a PDF
  • VectibixOpen a PDF - (Vectibix)
  • Viscosupplementation with Hyaluronic AcidOpen a PDF - Gel-One, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, TriVisc, Visco-3
  • XgevaOpen a PDF - (Xgeva)
  • XolairOpen a PDF - (omalizumab)
  • Zaltrap® Open a PDF - (ziv-aflibercept)