Excellus Bluecross BlueShield logo
Login | Register | Forgot Username | Forgot Password
Quick Links
Program Offerings
Check Our Drug List
Prior Authorization & Step Therapy
Quantity Limits
E-Prescribing
TransactRx Medicare Vaccines
Prescription Drug References for Practitioners
Prescription Drug References for Practitioners

Image Link: Get Adobe Reader You will need Acrobat® Reader to read and print PDF files. If you don't already have it, you can download it free at www.adobe.com.

  • General Medications
  • View or Print our Prior Authorization and Step Therapy Drug List
  • Specialty Rx Medication List (Self-Administered Drugs)
  • Medicaid Managed Care and Family Health Plus - Specialty Rx Medication List (Self-Administered Drugs)
  • Medical Specialty Drugs
  • List of Provider Administered Drugs Requiring Preauthorization
  • Drug Step Therapy Request Forms
  • Antihistamine & Intranasal Steroid - (Clarinex, Clarinex D, Levocetirizine, Xyzal)
  • Mental Health Prior Authorization Request - (Antidepressants, Antipsychotics, Mental Health Diagnosis)
  • PPI & Cholesterol - (Aciphex, Dexilant, Nexium, Prevacid, Prilosec, Protonix, Zegerid)
  • Drug Exception Forms
  • General Exception Request Form (Self Administered Drugs) - (used for requests that do not have a specific form above, or may be used to request an exception)
  • MAC Penalty Exception Request Form
  • Medicare Age-Restricted BEERS List Exception Form
  • Medicaid Managed Care Use Only
  • Standardized Prior Authorization Form - For Medicaid Managed Care/ Family Health Plus Members Only
  • Drug Prior Authorization Request Forms
  • Acthar - (Acthar)
  • Actimmune - (Actimmune)
  • Alpha 1 Anti-trypsin Therapy - (Aralast, Glassia, Prolastin, Zemaira)
  • Avastin - (Avastin)
  • Benlysta - (Benlysta)
  • Boniva IV, Reclast, Prolia - (Boniva IV, Reclast and Prolia)
  • Brand NSAIDs - (Arthrotec, Celebrex, Flector Patch, Ponstel)
  • Cimzia Crohn's (Health Professional Administered)
  • Cimzia Humira Crohns (Self Administered)
  • Clinical Review Prior Authorization - (Arzerra, Ceprotin, Folotyn, IIaris, Istodax, Jevtana, Kadcyla, Provenge, Soliris, Somatuline Depot, Torisel, Treanda)
  • Egrifta - (Egrifta)
  • Enteral - (Enteral)
  • Erbitux/Vectibix - (Erbitux/Vectibix)
  • ESA (Erythropoiesis Stimulating Agents) For Medicare Part D - (Aranesp, Epogen, Procrit)
  • Forteo - (Forteo)
  • Gilenya - (Gilenya)
  • Growth Hormone - (Omnitrope)
  • HAE (Hereditary Angioedema) - Provider Administered - (Berinert, Cinryze, Kalbitor)
  • HAE (Hereditary Angioedema) - Self Administered - (Cinryze, Firazyr)
  • Hepatitis B - (Baraclude, Epivir HBV, Hepsera, Tyzeka)
  • Hepatitis C - (Copegus, Infergen, PEG-Intron, Pegasys, Rebetol, Ribavirin, Incivek, Victrelis)
  • Inborn Errors of Metabolism - (Aldurazyme, Carbiglu, Cerezyme, Elaprase, Elelyso, Fabryzyme, Lumizyme, Myozyme, Naglazyme, Orfadin, Sucraid, Vpriv, Zavesca)
  • Infertility - (Bravelle, Cetrotide, corionic gonadotropin, Fertinex, Ganirelix, Gonal-F, Lupron, Luveris, Menopur, Novarel, Ovidrel, Pregnyl, Repronex)
  • IVIG & SCIG - (Carimune, Flebogamma, Gammagard, Gamunex, Hizentra, Octagan, Privigen, Vivagloban)
  • Kalydeco - (Kalydeco)
  • Korlym - (Korlym)
  • Krystexxa - (Krystexxa)
  • Kuvan PKU - (Kuvan PKU)
  • Makena - (Makena)
  • Nplate - (Nplate)
  • Nulojix - (Nulojix)
  • Nuvigil/ Provigil - (Nuvigil, Provigil)
  • Off-Label
  • Oncology (Health Professional Administered)
  • Oncology (Self Administered) - (Afinitor, Bosulif, Caprelsa, Cometriq, Erivedge, Hycamtin, Iclusig, Jakafi, Mekinist, Nexavar, Pomalyst, Revlimid, Sprycel, Sutent, Tafinlar, Tarceva, Tasigna, Tykerb, Votrient, Xalkori, Xtandi, Zelboraf, Zolinza, Zytiga)
  • Orencia IV - (Orencia IV)
  • Orencia SQ - (Orencia SQ)
  • Promacta - (Promacta)
  • Psoriasis - (Enbrel, Humira)
  • Pulmonary Arterial Hypertension - (Adcirca, Letairis, Revatio, Tracleer, Tyvaso)
  • Pulmonary Arterial Hypertension - (Flolan, Remodulin, Veletri, Ventavis)
  • Remicade - (Remicade)
  • Rheumatoid Arthritis - (Cimzia, Enbrel, Humira, Kineret, Simponi)
  • Sabril - (Sabril)
  • Stelara - (Stelara)
  • Synagis - (Synagis)
  • Tysabri Crohn's - (Tysabri Crohn's)
  • Tysabri Crohn's Recertification - (Tysabri Crohn's)
  • Tysabri MS - (Tysabri MS)
  • Xenical Belviq Qsymia - (Xenical, Belviq and Qsymia)
  • Xenical, Belviq, Qsymia Recertification - (Xenical, Belviq, Qsymia)
  • Xgeva - (Xgeva)
  • Xolair - (Xolair)
  • Zyvox - (Zyvox)
Home     News & Updates    Print Forms    About Us    Fraud & Abuse    Glossary    Accreditations   
Copyright © 2014, Excellus BlueCross BlueShield, a nonprofit independent licensee of the Blue Cross Blue Shield Association. All rights reserved. View our Privacy Policy for information on how we protect your privacy. Use of this site indicates your acceptance of our Terms of Use. Follow this link to view our 31 county New York State service area. You will need Internet Explorer or Firefox to use the secure features of this site.