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
AMPHETAMINES / DEXTROAMPHETAMINES
B C D E FFACTOR VIII, VIIIa, IX, XIII(Medical Benefit Only)
G H I JJOINT FLUID REPLACEMENT AGENTS
K L M N OOPHTHALMIC GLAUCOMA TREATMENTS
PPreservative-Free Morphine (Medical Benefit Only)
RRespiratory Syncytial Virus IG/ Synagis(MED. ONLY)
S TTOPICAL RETINOIC ACID DERIVATIVES
V X Z