Prior Authorization | MyBlue

This list shows prescription medications that require your doctor to obtain authorization from us.

You can download the Physician Request for Prior Authorization form (also called the Formulary Exception form).

Medications that Require Prior Authorization

(M) indicates the pre-authorization is only required for Medex and Blue Care^®65 members.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

AMPHETAMINES / DEXTROAMPHETAMINES

Astagraph XL (M)

Azathioprine (M)

B

Bevespi AeroSphere

Botulinium Toxin

C

Capecitabine (M)

Cyclosporine (M)

D

DIABETES TREATMENTS

E

ENTERAL FORMULA

Envarsus XR (M)

F

FACTOR VIII, VIIIa, IX, XIII(Medical Benefit Only)

Fentanyl Lozenge

G

H

Hydroxyprogesterone

I

Incruse Ellipta

INTERFERON (Alpha, Gamma)

IV Immunoglobulin (IVIG)

J

JOINT FLUID REPLACEMENT AGENTS

K

L

LONG ACTING PAIN MEDICATIONS

M

Mycophenolate (M)

Mycophenolic Acid (M)

N

NUTRTIONAL SUPPLEMENTS

O

OPHTHALMIC GLAUCOMA TREATMENTS

OVERACTIVE BLADDER AGENTS

P

Preservative-Free Morphine (Medical Benefit Only)

PROTON PUMP INHIBITORS (PPI)

R

Respiratory Syncytial Virus IG/ Synagis(MED. ONLY)

S

SHORT ACTING PAIN MEDICATIONS

T

Tacrolimus Topical

TOPICAL RETINOIC ACID DERIVATIVES

TOPICAL TESTOSTERONE

Tudorza Pressair

V

X

Z