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
Asthma Biologic Treatments
Xolair
Nucala
Fasenra
Botulinum Toxin Treatments
Dysport (preferred)
Botox
Myobloc
Xeomin
Colony-Stimulating Factors
Epoetin (Epogen/Procrit)
Enzyme Replacement Therapy
Aldurazyme
Brineura
Cerezyme
Elaprase
Elelyso
Fabrazyme
Kanuma
Lumizyme
Mepsevii
Naglazyme
Revcovi
Vimizim
Immune Globulins
Bivigam
Carimune NF
Inflammatory Biologics
Entyvio
Ilaris
Inflectra (not covered)
Remicade (no GF after 7/1/2019)
Renflexis
Soliris
Simponi Aria
Actemra IV
Orencia IV
Stelara IV
Interferons/Biologic Response Modifier
Interferon and Peginterferon for Hepatitis B
Luteinizing Hormone-Releasing Hormone (LHRH) Agonists
Lupron
Multiple Sclerosis
Lemtrada
Ocrevus
Others
Crysvita
HP Acthar
Makena (hydroxyprogesterone)
Nplate
Prolia
Rituxan (non-oncology)
Signifor LAR
Somatuline Depot
Synagis
Xiaflex

 

Additional Prescription Drug Policies & Preauthorization Forms