Prior Authorization

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

Abstral

Actemra

Acthar

Actiq

Actonel

Adcirca

Addyi

Advair

Alecensa

Amevive

AMPHETAMINES / DEXTROAMPHETAMINES

Ampyra

Armodafinil

Astagraph XL (M)

Atelvia

Atomoxetine

Avodart

Azasan (M)

Azathioprine (M)

B

Belviq

Belviq XR

Bevespi AeroSphere

Binosto

Boniva

Botulinium Toxin

Buprenex

C

Capecitabine (M)

Capxib

Celebrex

Celecoxib

Cellcept (M)

Ceredase

Cerezyme

Cimzia

Cinqair

Cinryze

Cosentyx

Cotellic

Cyclosporine (M)

Cytoxan (M)

D

Daklinza

Desoxyn

DIABETES TREATMENTS

Dificid

Dulera

Dupixent

Dysport

E

Egrifta

Elidel

Enbrel

ENTERAL FORMULA

Entyvio

Envarsus XR (M)

Epclusa

ERYTHROPOIETIN

Exondys 51

F

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

Farydak

Fentanyl Lozenge

Fentora

Forteo

Fosamax

G

Gengraf (M)

Grastek

GROWTH HORMONE

H

Harvoni

Hecoria (M)

Hetlioz

Humira

Hydroxyprogesterone

I

Ibandronate

Ibrance

Idhifa

Ilaris

Imogan (M)

Imovax (M)

Imuran (M)

Incruse Ellipta

Inflectra

INTERFERON (Alpha, Gamma)

IV Immunoglobulin (IVIG)

J

Jalyn

JOINT FLUID REPLACEMENT AGENTS

Juxtapid

K

Kalydeco

Kevzara

Kineret

Kisqali

Kisqali Femara

Kynamro

L

Lazanda

Lenvima

Lidoxib

LONG ACTING PAIN MEDICATIONS

Lynparza

Lyrica

M

Makena

Mekinist

Mirapex

Mirapex ER

Modafinil

Myalept

Mycophenolate (M)

Mycophenolic Acid (M)

Myfortic (M)

N

Neoral (M)

Nucala

NUTRTIONAL SUPPLEMENTS

Nuvigil

O

Olysio

Onsolis

Opdivo

OPHTHALMIC GLAUCOMA TREATMENTS

Oralair

Orencia

Orkambi

Otezla

OVERACTIVE BLADDER AGENTS

P

Praluent

Preservative-Free Morphine (Medical Benefit Only)

Prograf (M)

Prolastin

Prolia

Proscar

PROTON PUMP INHIBITORS (PPI)

Protopic

Provigil

R

Rabavert (M)

Ragwitek

Rapamune (M)

Raptiva

Reclast

Regranex

Remicade

Renflexis

Repatha Requip

Requip XL

Respiratory Syncytial Virus IG/ Synagis(MED. ONLY)

Restasis

Revatio

Rituxan

Rydapt

S

Sandimmune (M)

Saxenda

SHORT ACTING PAIN MEDICATIONS

Sildenafil

Simponi

Simulect (M)

Sirolimus (M)

Solvaldi

Spinraza

Stelara

Strattera

Subsys

Symbicort

T

Tacrolimus (M)

Tacrolimus Topical

Tafinlar

Taltz

Technivie

TOPICAL RETINOIC ACID DERIVATIVES

TOPICAL TESTOSTERONE

Tudorza Pressair

Tymlos

Tysabri

V

Vectibix

Venclexta

Vepesid (M)

Victrelis

Viekira PAK

Vosevi

X

Xalkori

Xeljanz

Xeljanz XR

Xeloda (M)

Xeomin

Xgeva

Xiidra

Xolair

Z

Zelboraf

Zenapax (M)

Zepatier

Zometa

Zortess (M)

Zydelig

Zykadia