Prescription Drug References for Members

  • Step Therapy Forms:
  • Antihistamine & Intranasal Steroid - (Clarinex, Clarinex D, Levocetirizine, Xyzal)
  • Mental Health Prior Authorization Request - (Antidepressants, Antipsychotics, Mental Health Diagnosis)
  • Prior Authorization Forms for Drugs Covered Under Medicare Part D:
  • Zyvox (linezolid) & Sivextro (tedizolid phosphate) - Zyvox (linezolid) & Sivextro (tedizolid phosphate)
  • Xolair - (Xolair)
  • Tysabri MS - (Tysabri MS)
  • Tysabri Crohn's Recertification - (Tysabri Crohn's)
  • Tysabri Crohn's - (Tysabri Crohn's)
  • Synagis - (Synagis)
  • Stelara (For Crohn's Disease) - (Stelara)
  • Rheumatoid Arthritis - (Actemra, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Simponi) Inflammatory Conditions (RA, PsA, AS) self-administered medications
  • Remicade, Renflexis - (Remicade, Renflexis)
  • Pulmonary Arterial Hypertension - (Adcirca, Letairis, Revatio, Tracleer, Tyvaso, Uptravi)
  • Provigil - (Provigil)
  • Promacta - (Promacta)
  • Orencia IV - (Orencia IV)
  • Mozobil - (Mozobil)
  • Lupron - (Lupron)
  • Hepatitis C Recertification - (Copegus, Infergen, PEG-Intron, Pegasys, Rebetol, Ribavirin)
  • Hepatitis B - (Baraclude, Epivir HBV, Hepsera, Tyzeka)
  • Prolia - (Prolia)
  • Xenical, Belviq, Belviq XR, Qsymia, New Start & Recertification - (Xenical, Belviq, Belviq XR, Qsymia)
  • Xenical, Saxenda, Qsymia, Contrave, Belviq, Belviq XR - Belviq, Belviq XR, Contrave, Qsymia, Saxenda, Xenical
  • Amevive - (Amevive)
  • Actemra IV (Health Professional Administered)
  • Additional Forms:
  • Quantity Limit Exception Form
  • General Exception Request Form (Self Administered Drugs) - (used for requests that do not have a specific form below, or may be used to request an exception)
Univera Healthcare contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Univera Healthcare depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. .
This page last updated .