Preauthorzation

Click here for information on referrals and the list of services that require preauthorization.

Prescription Drugs Requiring Preauthorization

Please use our Medication Preauthorization Form for the following medications:

 

 

Alpha-1 Proteinase Inhibitors
Aralast-NP
Glassia
Prolastin-C
Zemaira
Antiarrhythmic
Antiarrhythmic Drug BetaPace Induction
Antihemophilic Factors
Antihemophilic Factor VIII
Antihemophilic Factor XI
Emicizumab-KXWH
Hemlibra
Hyaluronan
Antirheumatic
Euflexxa
Asthma Biologic Treatments
Xolair
Nucala
Fasenra
Botulinum Toxin Treatments
Botox
Botulinum
Dysport (preferred)
Myobloc
Xeomin
C1 Esterase Inhibitor
Berinert
Cinryze
Haegarda
Ruconest
Colony-Stimulating Factors
Epoetin (Epogen/Procrit)
Filgrastim
Nivestym
Nplate
Pegfilgrastim-Ziextenzo
Enzyme Replacement Therapy
Adagen
Aldurazyme
Brineura
Cerezyme
Elaprase
Elelyso
Fabrazyme
Kanuma
Lumizyme
Mepsevii
Naglazyme
Revcovi
Vimizim
Vpriv
Immune Globulins
Bivigam
Carimune NF
Cinqair
Cuvitru
Flebogamma
GamaSTAN
Gammagard
Gammaplex
Gamunex
Hizentra (SC only)
HyQvia (SC only)
Octagam
Privigen
Xembify – effective 1/1/2020
Zinplava – effective 1/1/2020
Inflammatory Biologics
Actemra IV
Cimzia
Entyvio
Hydroxychloroquine
Ilaris
Inflectra (not covered).
Ixifi
Methotrexate
Orencia IV
Remicade (no GF after 7/1/2019)
Renflexis
Soliris
Simponi Aria
Stelara IV
Ustekinumab
Vectra DA
Interferons/Biologic Response Modifier
Interferon and Peginterferon for Hepatitis B
Luteinizing Hormone-Releasing Hormone (LHRH) Agonists
Lupron
Kallikrein Inhibitor
Kalbitor
Takhzyro – effective 1/1/2020
Multiple Sclerosis
Lemtrada
Ocrevus
Ophthalmic Agent
Eylea
Lucentis
Macugen
Others
Aranesp
Aripiprazole lauroxil
Beuprenorphine Implant
Cerliponase Alfa
Crizanlizumab – effective 4/1/2020
Crysvita
Firazyr
Flolan
Fulphila
HP Acthar
Hydroxyprogesterone Caproate
Makena (hydroxyprogesterone)
Neulasta
Neulasta OnPro
Neupogen
Nivestym
Paricalcitol
Parsabiv – effective 1/1/2020
Prolia
Rituxan (non-oncology)
Signifor LAR
Somatuline Depot
Supprelin LA
Synagis
Trogarzo – effective 1/1/2020
Udenyca – effective 5/15/2020
Xgeva
Xiaflex
Zarxio
Prostaglandin
Flolan – effective 1/1/2020
Remodulin
Veletri
siRNA Agent
Onpattro – effective 1/1/2020
Patisiran

 

Additional Prescription Drug Policies & Preauthorization Forms