Prior Authorization (PA) 2024
There are three reasons for the use of prior authorization: scope controls, utilization controls and product based controls. This section includes the list of medications requiring Prior Authorization (PA). PA forms can be found in the Pharmacy Forms section. Incomplete forms will result in either a delay or denial. Please ensure all forms are submitted with all the necessary information to efficiently process the request for the member.
Therapeutic Categories:
- Anti-Infectives - Cephalosporins, Ketoconazole Oral Tablets, Skin and Soft Tissue, Special Formulations
- Biologics - Botulinum toxins, Hematopoetic, Immunomodulating, Replacement Therapy, Respiratory, Skeletal
- Cardiovascular - Anticoagulants, Antihypertensives, Antiplatelet, Antihyperlipidemics, Clonidine Products, Hereditary Angioedema, Pulmonary Arterial Hypertension, Revatio
- Central Nervous System/Behavioral Health - ADHD & Narcolepsy, Alzheimer's, Antidepressants, Anti-Migraine, Anxiolytic/Hypnotic, Atypical Antipsychotics, Fibromyalgia, Multiple Sclerosis, Narcotic Analgesics, Parkinson's, Restless Leg Syndrome, Requip XL/Mirapex ER, Smoking Cessation, Substance Abuse Treatment
- Chelating/Binding Agents - Ferriprox, Jadenu
- Diabetes/Endocrine - Diabetic Medications, Erythropoietin Stimulating Agents, Growth Hormone, Makena®, Testosterone, Vitamin D Analogs
- Gastrointestinal - Amitiza, Anti-emetic, Anti-Ulcer, Bowel Prep, Pancreatic Enzymes
- Genetic Disorders - Cerdelga®, Cerezyme®, Elelyso®, Exondys 51™, Spinraza™, Vpriv®, Zavesca®
- Genitourinary System - Benign Prostatic Hyperplasia (BPH), Bladder Control Drugs
- Hemophilia - Adynovate, Alprolix, Coagadex, Corifact, Eloctate, Idelvion, Obizur, Tretten
- Hepatic Disorders - Harvoni, Mavyret, Sofosbuvir/Velpatasvir (Epclusa), Sovaldi, Vosevi, Zepatier
- HIV Medications
- Intravenous Iron Therapy
- Metabolic Disorders- Cholbam, Kanuma, Keveyis, Myalept, Procysbi, Ravicti, Strensiq
- Ocular/Otic - Ocular Allergy, Ophthalmic Anti-Infective/Steroid, Ophthalmic Corticosteroid, Ophthalmic NSAIDs, Ophthalmic Glaucoma, Otic Anti-Infective
- Oncologic Therapies - Afinitor, Breast Cancer, Prostate Cancer, Skin Cancer
- Opioid Reversal Agents - Nalmefene HCL, Naloxone HCL, Generic Naloxone
- Respiratory - Asthma & COPD Inhalation Medications, Antihistamines, Leukotriene Modifiers, Nasal Allergy Sprays, Pulmonary Arterial Hypertension, Pulmonary Fibrosis, Synagis, Tobi/Pulmozyme, Xolair
- Skeletal System - Amrix & Fexmid, Bisphosphonates, Forteo, Gout, NSAIDs, Skeletal Muscle Relaxants, Soma
- Special Formulations - Millipred®, Veripred 20®
- Topical - Antifungal, Elidel/Protopic, Pediculicides, Topical Antibiotic Medications, Topical Corticosteroids
Last Modified on
Sep 30, 2025
