PROVIDERS

Drug-Specific Prior Authorization

If the drug that you wish to prescribe is shown on this page, please click on it to download its associated Prior Auth form. Using the appropriate form will help assure that we have all the information needed to make a decision about your request.

  Abilify (as Adjuctive Therapy)
  Aciphex
  Avonex
  Baraclude
  Betaseron
  Botox
  Byetta
  Celebrex
  Copaxone
  Enbrel
  Erythropoietins - Initial
  Erythropoietins - Renewal
  Fuzeon - Initial
  Fuzeon - Renewal
  Genotropin - Initial
  Genotropin - Renewal
  Humatrope - Initial
  Humatrope - Renewal
  Humira
  Hyaluronic Acid Derivatives - Initial
  Hyaluronic Acid Derivatives - Renewal
  Kapidex - Dexilant
  Kineret
  Leuprolide for Men
  Lupron Depot - Pediatric
  Lupron Depot for Females
  Lyrica
  Marinol
  Megace
  Nexium
  Norditropin - Initial
  Norditropin - Renewal
  Nutropin AQ, Nutropin
  Orencia
  Oxandrin
  Oxycontin
  Pegasys with ribavirin (HEP C)-Initial
  Pegasys with ribavirin (HEP C)-Renewal
  Peg-Intron with ribavirin (HEP C)-Initial
  Peg-Intron with ribavirin (HEP C)-Renewal
  Prevacid
  Procrit - Initial
  Procrit - Renewal
  Proton Pump Inhibitors
  Protonix
  Rebif (Interferon Beta)
  Remicade
  Restasis
  Risperdal Consta - Initial
  Risperdal Consta - Renewal
  Saizen - Initial
  Saizen - Renewal
  Serostim
  Simponi
  Soliris - Initial
  Soliris - Renewal
  Suboxone - Initial
  Suboxone - Renewal
  Subutex - Initial
  Subutex - Renewal
  Symlin
  Synagis
  Tysabri
  Xolair - Initial
  Xolair - Renewal
  Zoladex
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