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:

 

 

<tr>Hymovis (hyaluronate derivative)

Alpha-1 Proteinase Inhibitors
Aralast-NP
Glassia
Prolastin-C
Zemaira
Antiarrhythmic
Antiarrhythmic Drug BetaPace Induction
Antihemophilic Factors
Alprolix
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
Granix
Nivestym
Nplate
Pegfilgrastim-Ziextenzo
Enzyme Replacement Therapy
Adagen
Aldurazyme
Brineura
Cerezyme
Elaprase
Elelyso
Fabrazyme
Kanuma
Lumizyme
Mepsevii
Myozyme (aglucosiderase)
Naglazyme
Revcovi
Vimizim
Vpriv
Hyaluronate derivative
Triluron (hyaluronate derivative)
Visco-3 (hyaluronate derivative)
Vyepti (eptinezumab)
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
Beovu (brolucizumab)
Eylea
Lucentis
Macugen
Others
Aranesp
Aripiprazole lauroxil
Beuprenorphine Implant
Cerliponase Alfa
Cimzia
Crizanlizumab – effective 4/1/2020
Crysvita
Durolane (hyaluronate derivative)
Enfortumab vedotin-ejfv, 0.25 mg
Firazyr
Flolan
Fulphila
Gel-One (hyaluronate derivative)
Gelsyn-3 (hyaluronate derivative)
Gemcitabine hydrochloride, (Infugem), 100 mg
GenVisc 850 (hyaluronate derivative)
HP Acthar
Hyalgan (hyaluronate derivative)
Hydroxyprogesterone Caproate
Kadcyla (trastuzumab)
Makena (hydroxyprogesterone)
Melphalan (Evomela), 1 mg
Monovisc (hyaluronate derivative)
Neulasta
Neulasta OnPro
Neupogen
Nivestym
Ontruzant (trastuzumab)
Orthovisc (hyaluronate derivative)
Paricalcitol
Parsabiv – effective 1/1/2020
Prolia
Retacrit
Rituxan (non-oncology)
Ruxience (rituximab)
Signifor LAR
Somatuline Depot
Supartz (hyaluronate derivative)
Supprelin LA
Synagis
Synojoynt
Synvisc (hyaluronate derivative)
Synvisc-One (hyaluronate derivative)
Tepezza (teprotumumab)
Trastuzumab deruxtecan-nxki, 1 mg
Trazimera (trastuzumab)
Trogarzo – effective 1/1/2020
Udenyca – effective 5/15/2020
Xgeva
Xiaflex
Zarxio
Prostaglandin
Flolan – effective 1/1/2020
Remodulin
Veletri
siRNA Agent
Givlaari (givosiran)
Onpattro – effective 1/1/2020
Patisiran

 

Additional Prescription Drug Policies & Preauthorization Forms