Prior Authorization is required for the following medications because they may have limited conditions for which they are prescribed; special monitoring or dispensing requirements; or an extremely high cost. Guidelines for approving coverage for prior authorization drugs are developed and approved by a panel of practicing physicians and pharmacists. Click on the drug name to view the specific prior authorization guidelines.
Oforta PA Onfi PA Orencia PA Promacta PA Qualaquin PA Qutenza PA Ranexa PA Relistor PA Revatio_Adcirca PA Revlimid PA Ribavirin PA Rilutek PA Sandostatin PA Sabril PA Samsca PA Simponi PA Soliris PA Criteria Sprycel PA Stivarga PA Suboxone PA Subsys PA Sutent PA Sylatron PA Symlin PA Synarel PA Tasigna PA Topical Retinoid Medications PA Tracleer PA Tykerb PA Vandetanib PA Ventavis_Tyvaso PA Victrelis_Incivek PA Votrient PA Xalkori PA Xarelto PA Xeljanz PA Xenazine PA Xtandi PA Zavesca PA Zelboraf PA Zortress PA Zytiga PA Zyvox PA
Commercial-Only Guidelines: Actiq PA (Commercial Only) Erythropoiesis Stimulating Agents PA (Commercial Only) Interferon Alfa for Hepatitis PA (Commercial Only) Isotretinoin PA (Commercial Only) Korlym PA (Commercial Only) Lazanda PA (Commercial Only) Multiple Sclerosis Agents PA (Commercial Only) Nuvigil PA (Commercial Only) Provigil PA (Commercial Only) Somavert PA (Commercial Only) Xifaxan PA (Commercial Only) Xyrem PA (Commercial Only)
Medicare-Only Guidelines: Actemra PA (Medicare Only) Actiq PA_QL (Medicare Only) Adagen PA (Medicare Only) Alferon N PA (Medicare Only) Alpha Proteinase Inhibitors PA (Medicare Only) Antiemetics PA (Medicare Only) Benlysta PA (Medicare Only) Egrifta PA (Medicare Only) Erythropoiesis Stimulating Agents PA (Medicare Only) Growth Hormone PA (Medicare Only) Halaven PA (Medicare Only) Human Chorionic Gonadotropins PA (Medicare Only) Interferon Alfa for Hepatitis PA (Medicare Only) IVIG PA (Medicare Only) Kyprolis PA (Medicare Only) Lazanda PA (Medicare Only) Marinol PA (Medicare Only) Miacalcin PA (Medicare Only) Multiple Sclerosis Agents PA (Medicare Only) Naglazyme PA (Medicare Only) Nuvigil PA (Medicare Only) Perjeta PA Criteria (Medicare Only) Prolia PA Criteria (Medicare Only) Provigil PA (Medicare Only) Stelara PA (Medicare Only) Xeomin PA (Medicare Only) Xyrem PA (Medicare Only) Yervoy PA (Medicare Only) Zaltrap PA (Medicare Only)