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Prescription Drug References for Practitioners
Prescription Drug References for Practitioners
  • General Medications
  • Commercial 3-Tier Prior Authorization and Step Therapy Medication List
  • Child Health Plus Prior Authorization and Step Therapy Medication List
  • Medicaid Managed Care Prior Authorization and Step Therapy Medication List
  • Specialty Rx Medication List (Self-Administered Drugs)
  • Medicaid Managed Care - 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)
  • Generic Advantage Program/ MAC Penalty Exception Request Form
  • Medicare Age-Restricted BEERS List Exception Form
  • Medicare D Chronic Insomnia - Request for Drug Evaluation
  • Medicare D End Stage Renal Disease - Request for Drug Evaluation
  • Medicare D Hospice - Request for Drug Evaluation
  • Medicare D Lidocaine Patch & Flector Patch - Request for Drug Evaluation
  • Medicaid Managed Care Use Only
  • Standardized Prior Authorization Form - For Medicaid Managed Care
  • Drug Prior Authorization Request Forms
  • Actemra - Actemra
  • Acthar - (Acthar)
  • Actimmune - (Actimmune)
  • Alpha 1 Anti-trypsin Therapy - (Aralast, Glassia, Prolastin, Zemaira)
  • Anemia - (applies to Epogen, Procrit, and Aranesp)
  • Avastin - (Avastin)
  • Benlysta - (Benlysta)
  • Boniva IV, Prolia - (Boniva IV, 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)
  • Compounded Drug Products
  • Egrifta - (Egrifta)
  • Enteral - (Enteral)
  • Entyvio - Entyvio
  • 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)
  • Halaven - Halaven
  • Hepatitis B - (Baraclude, Epivir HBV, Hepsera, Tyzeka)
  • Hepatitis C - (Daklinza, Harvoni, Incivek, Olysio, PEG-Intron, Pegasys, Ribavirin, Sovaldi, Technivie, Victrelis, Viekira)
  • 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)
  • Lemtrada - Lemtrada
  • Makena - (Makena)
  • Marqibo - Marqibo
  • Metastatic Melanoma - Yervoy, Keytruda, Opdivo
  • Mozobil - Mozobil
  • Nplate - (Nplate)
  • Nulojix - (Nulojix)
  • Nuvigil/ Provigil - (Nuvigil, Provigil)
  • Off-Label
  • Oncology (Health Professional Administered)
  • Oncology (Self Administered) - (Afinitor, Beleodaq, Blincyto, Bosulif, Caprelsa, Cometriq, Erivedge, Hycamtin, Iclusig, Jakafi, Mekinist, Nexavar, Pomalyst, Revlimid, Sprycel, Sutent, Tafinlar, Tarceva, Tasigna, Tykerb, Votrient, Xalkori, Xtandi, Zelboraf, Zolinza, Zytiga)
  • Onychomycosis - Jublia, Kerydin, Onmel
  • Orencia IV - (Orencia IV)
  • Orencia SQ - (Orencia SQ)
  • Perjeta - Perjeta
  • Promacta - (Promacta)
  • Psoriasis - (Cosentyx, Enbrel, Humira, Otezla)
  • 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)
  • Simponi Aria - Simponi Aria
  • Stelara - (Stelara)
  • Synagis - (Synagis)
  • Testosterone - Testosterone
  • Tysabri Crohn's - (Tysabri Crohn's)
  • Tysabri Crohn's Recertification - (Tysabri Crohn's)
  • Tysabri MS - (Tysabri MS)
  • Xenical Belviq Qsymia Contrave - (Xenical, Belviq, Qsymia and Contrave)
  • Xenical, Belviq, Qsymia Recertification - (Xenical, Belviq, Qsymia)
  • Xgeva - (Xgeva)
  • Xolair - (Xolair)
  • Zaltrap - Zaltrap
  • Zyvox (linezolid) & Sivextro (tedizolid phosphate) - Zyvox (linezolid) & Sivextro (tedizolid phosphate)