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
Hyaluronan
Asthma Biologic Treatments
Xolair
Nucala
Fasenra
Botulinum Toxin Treatments
Dysport (preferred)
Botox
Myobloc
Xeomin
C1 Esterase Inhibitor
Berinert
Cinryze
Haegarda
Ruconest
Colony-Stimulating Factors
Epoetin (Epogen/Procrit)
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
Ilaris
Inflectra (not covered).
Ixifi
Orencia IV
Remicade (no GF after 7/1/2019)
Renflexis
Soliris
Simponi Aria
Stelara IV
Ultomiris
Ustekinumab
Interferons/Biologic Response Modifier
Interferon and Peginterferon for Hepatitis B
Iron Product
Feraheme
Injectafer
Luteinizing Hormone-Releasing Hormone (LHRH) Agonists
Lupron
Kallikrein Inhibitor
Kalbitor
Takhzyro – effective 1/1/2020
Multiple Sclerosis
Lemtrada
Ocrevus
Ophthalmic Agent
Lucentis
Macugen
Others
Aripiprazole (Others) antipsychotic
Beuprenorphine Implant
Crysvita
Eylea
Flolan
HP Acthar
Makena (hydroxyprogesterone)
Nplate
Paricalcitol
Parsabiv – effective 1/1/2020
Prolia
Rituxan (non-oncology)
Signifor LAR
Somatuline Depot
Supprelin LA
Synagis
Trogarzo – effective 1/1/2020
Xgeva
Xiaflex
Prostaglandin
Flolan – effective 1/1/2020
Remodulin
Veletri
siRNA Agent
Onpattro – effective 1/1/2020
Patisiran

 

Additional Prescription Drug Policies & Preauthorization Forms