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You and your staff can request a coverage determination electronically, directly from your electronic medical record (EMR) or through CoverMyMeds ePA portal. Visit covermymeds.com for additional information on CoverMyMeds and electronic prior authorizations.

  • General Medications
  • Commercial 3-Tier Prior Authorization and Step Therapy Medication ListOpen a PDF
  • Medicaid Managed Care Prior Authorization Step Therapy Medication ListOpen a PDF
  • Specialty Rx Medication List (Self-Administered Drugs)Open a PDF
  • Medical Specialty Drugs
  • List of Provider-Administered Medical Specialty Drugs for Commercial, Exchange, Medicare Managed Care Requiring PreauthorizationOpen a PDF
  • Provider-Administered Medical Specialty Drugs Requiring Preauthorization-Medicaid Managed Care, Child Health Plus membersOpen a PDF
  • Drug Step Therapy Request Forms
  • Request for Step Therapy Evaluation Prior Auth FormOpen a PDF
  • Medicaid Managed Care Use Only
  • Standardized Prior Authorization FormOpen a PDF - For Medicaid Managed Care
  • Drug Exception Forms
  • General Exception Request Form (Self Administered Drugs)Open a PDF
  • Generic Advantage Program/ MAC Penalty Exception Request Form Open a PDF
  • Medicare D End Stage Renal Disease - Request for Drug EvaluationOpen a PDF
  • Medicare D ESA (Erythropoiesis Stimulating Agents) - Request For Drug Evaluation (Self Administration)Open a PDF - (Aranesp, Epogen, Procrit)
  • Medicare D Hospice - Request for Drug EvaluationOpen a PDF
  • Medicare D Lidocaine Patch & Flector Patch - Request for Drug EvaluationOpen a PDF
  • Medicare D Opioid Prior Authorization Form - Request for Drug & Morphine Milligram Equivalents ReviewOpen a PDF
  • Medicare D Sulfonylurea - Request for Drug Evaluation Open a PDF
  • Drug Prior Authorization Request Forms
  • ActharOpen a PDF - (H.P. Acthar Gel (Repository Corticotropin Injection)
  • Actemra IV (Health Professional Administered)Open a PDF
  • AdcetrisOpen a PDF - (Adcetris)
  • AliqopaOpen a PDF - (Aliqopa)
  • Alpha 1 Anti-trypsin Therapy (AAT)Open a PDF - (Aralast NP, Grassia, Prolastin-C, Zemaira)
  • Anemia (Self Administered)Open a PDF - (Aranesp,Epogen, Procrit)
  • AvastinOpen a PDF - (Avastin)
  • Benlysta IVOpen a PDF - (Benlysta IV)
  • Benlysta SC Open a PDF - (Benlysta SC)
  • Blood ModifiersOpen a PDF - (Fulphila, Granix, Neupogen, Nivestym)
  • Cimzia (Health Professional Administered)Open a PDF - (Crohn's & R.A.)
  • Clinical Review Prior Authorization (Medical) For Healthcare Professional Administration Only Open a PDF - Ajovy, Benlysta IV, Ceprotin, Hydroxyprogesterone, Ilaris, Krystexxa, Lemtrada, Luxturna, NPlate, Nulojix, Ocrevus, Radicava, Signifor LAR, Soliris, Sylvant, Trogarzo, Ultomiris
  • Clinical Review Prior Authorization (Rx) Open a PDF
  • Compounded Drug ProductsOpen a PDF
  • Dupixent Open a PDF - (dupilumab)
  • Egrifta Open a PDF - (Egrifta)
  • Enteral Open a PDF - (Enteral)
  • EntyvioOpen a PDF - (Crohn's Disease & Ulcerative Colitis)
  • FirmagonOpen a PDF - (Previously Degarelix)
  • Forteo,Tymlos Open a PDF - (Osteoporosis)
  • GilenyaOpen a PDF - (Multiple Sclerosis)
  • HAE (Hereditary Angioedema) - Health Professional AdministeredOpen a PDF - (Berinert, Cinryze, Kalbitor, Ruconest)
  • HAE (Hereditary Angioedema) - Self AdministeredOpen a PDF - (Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro)
  • Halaven (eribulin)Open a PDF - (Metastatic Breast Cancer)
  • Hepatitis COpen a PDF - Daklinza, Epclusa, Harvoni, Olysio, Pegasys, PEG-Intron, Ribavirin, Sovaldi, Technivie, Viekira, Vosevi, Zepatier
  • ILumyaOpen a PDF - (For Psoriasis (Health Professional Administered))
  • ImmuneGlobulin: Intravenous (IVIG) and Subcutaneous (SCIG)Open a PDF - Carimune, Flebogamma, Gammagard, Gamunex, Gammaked, Hizentra, HyQvia, Octagan, Privigen, Bivigam
  • Inborn Errors of Metabolism & Rare Genetic Diseases (Health Professional Administration)Open a PDF - Adagen (pegademase bovine, Rx), Aldurazyme (laronidase, Medical),, Brineura (cerliponase alfa, Medical), Carbaglu (carglumic acid, Rx), Cerdelga (eliglustat, Rx), Cerezyme (imiglucerase,Medical), Cholbam (cholic acid, Rx), Crysvita (burosumab-twza, Medical), Elaprase (idursulfase, Medical), Elelyso (taliglucerase alfa, Medical), Fabrazyme (agalisidase beta, Medical), Galafold (migalastat, Rx), Gamifant (emapalumab-lzsg, Medical), Kanuma (sebelipase alfa, Medical), Kuvan (sapropterin, Rx), Lumizyme (alglucosidase alfa, Medical), Mepsevii (vestronidase alfa-vjbk, Medical), Naglazyme (galsulfase, Medical), Nityr (nitisinone, Rx), Onpattro (patisiran, Medical), Orfadin (nitisinone, Rx), Palynziq (pegvaliase-pqpz, Rx), Ravicti (glycerol phenylbutyrate, Rx), Revcovi (elapegademase-lvlr, Rx), Strensiq (asfotase alfa, Rx), Sucraid (sacrosidase, Rx), Tegsedi (inotersen, Rx), Vimizim (elosulfase alfa Medical), VPRIV (velaglucerase alfa Medical), Xuriden (uridine triacetate, Rx), Zavesca (miglustat Rx)
  • Inborn Errors of Metabolism & Rare Genetic Diseases (Self Administration)Open a PDF - Adagen (pegademase bovine, Rx), Aldurazyme (laronidase, Medical),, Brineura (cerliponase alfa, Medical), Carbaglu (carglumic acid, Rx), Cerdelga (eliglustat, Rx), Cerezyme (imiglucerase,Medical), Cholbam (cholic acid, Rx), Crysvita (burosumab-twza, Medical), Elaprase (idursulfase, Medical), Elelyso (taliglucerase alfa, Medical), Fabrazyme (agalisidase beta, Medical), Galafold (migalastat, Rx), Gamifant (emapalumab-lzsg, Medical), Kanuma (sebelipase alfa, Medical), Kuvan (sapropterin, Rx), Lumizyme (alglucosidase alfa, Medical), Mepsevii (vestronidase alfa-vjbk, Medical), Naglazyme (galsulfase, Medical), Nityr (nitisinone, Rx), Onpattro (patisiran, Medical), Orfadin (nitisinone, Rx), Palynziq (pegvaliase-pqpz, Rx), Ravicti (glycerol phenylbutyrate, Rx), Revcovi (elapegademase-lvlr, Rx), Strensiq (asfotase alfa, Rx), Sucraid (sacrosidase, Rx), Tegsedi (inotersen, Rx), Vimizim (elosulfase alfa Medical), VPRIV (velaglucerase alfa Medical), Xuriden (uridine triacetate, Rx), Zavesca (miglustat Rx)
  • Infertility Open a PDF - (Bravelle, Cetrotide, corionic gonadotropin, Fertinex, Ganirelix, Gonal-F, Lupron, Luveris, Menopur, Novarel, Ovidrel, Pregnyl)
  • (Infliximab) Remicade, (infliximab-abda) RenflexisOpen a PDF - (Infliximab) Remicade, (infliximab-abda) Renflexis
  • Interleukin AntagonistsOpen a PDF - Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)
  • KalydecoOpen a PDF - (Cystic Fibrosis)
  • KorlymOpen a PDF - (Cushing's Syndrome)
  • KrystexxaOpen a PDF - (Gout)
  • Kuvan Open a PDF - (PKU)
  • Lemtrada (alemtuzumab)Open a PDF - (Multiple Sclerosis)
  • MarqiboOpen a PDF - (liposomal vincristine)
  • Medication Duplication Safety Edit RequestOpen a PDF
  • MozobilOpen a PDF - (Mozobil)
  • NplateOpen a PDF - (For ITP)
  • NulojixOpen a PDF - (Nulojix)
  • Off-LabelOpen a PDF
  • Oncology (Health Professional Administered)Open a PDF - Adcetris, Aliqopa, Arzerra, Bavencio, Beleodaq, Belrapzo, Bendeka, Besponsa, Blincyto, Cyramza, Darzalex, Elzonris, Empliciti, Erwinaze, Folotyn, Gazyva, Halaven, Herceptin Hylecta, Imfinzi, Istodax, Jevtana, Kadcyla, Keytruda, Kymriah, Kyprolis, Lartruvo, Libtayo, Lumoxiti, Marqibo, Mozobil, Mylotarg, Oncaspar, Onivyde, Opdivo, Perjeta, Portrazza, Provenge, Synribo, Tecentriq, Torisel, Vyxeos, Xgeva, Yervoy, Yescarta, Yondelis, Zaltrap
  • Oncology (Self Administration)Open a PDF - Afinitor, Alecensa, Alunbrig, Bosulif, Braftovi, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Daurismo, Erivedge, Erleada, Farydak, Gilotrif, Hycamtin, Ibrance, Iclusig, Imbruvica, Inlyta, Iressa, Jakafi, Kisqali, Lenvima, Lonsurf, Lorbrena, Lynparza, Mekinist, Mektovi, Mozobil, Nerlynx, Nexavar, Ninlaro, Odomzo, Pomalyst, Purixan, Revlimid, Rubraca, Rydapt, Soltamox, Sprycel, Stivarga, Sutent, Sylatron Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin,Tasigna, Tibsovo, Tykerb, Valchlor, Venclexta, Verzenio, Vitrakvi, Vizimpro, Votrient, Xalkori, Xermelo, Xospata, Xtandi, Yonsa, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga
  • OnychomycosisOpen a PDF - Jublia, Kerydin, Onmel
  • Opioid Prior Authorization Request Form for Drug and Morphine Milligram Equivalents ReviewsOpen a PDF
  • Orencia IV (Health Professional Administration)Open a PDF - (Orencia, abatacept for RA & JIA)
  • Orencia SQOpen a PDF - (abatacept, Orencia for RA & JIA)
  • OsteoporosisOpen a PDF - (Evenity, Prolia)
  • PCSK9 Inhibitors Open a PDF - Praluent, Repatha
  • ProliaOpen a PDF - (Osteoporosis)
  • PsoriasisOpen a PDF - (Cosentyx, Enbrel, Humira, Otezlaļƒ¢
  • Pulmonary Arterial Hypertension (Health Professional Administered)Open a PDF - (epoprostenol, treprostinil, Flolan, Remodulin, Veletri, Ventavis)
  • Pulmonary Arterial Hypertension (Self Administration)Open a PDF - (Adcirca, Adempas, Letairis, Opsumit, Orenitram, Revatio, sildenafil, tadalafil, Tracleer, Tyvaso, Uptravi)
  • Rituxan, Rituxin Hycela (Health Professional Administered)Open a PDF - (For Medicaid Managed Care)
  • Simponi Aria (Health Professional Administration)Open a PDF - (Rheumatoid Arthritis)
  • SpravatoOpen a PDF - (esketamine nasal spray)
  • Stelera (Healthcare Professional Administered)Open a PDF - (Crohn's Disease)
  • Stelera (Self Administration)Open a PDF - (For Crohn's Disease)
  • Stelara (Health Professional Administration)Open a PDF - (For Psoriasis or Psoriatic Arthritis)
  • Stelera (Self-Administration)Open a PDF - (For Psoriasis or Psoriatic Arthritis)
  • Synagis Open a PDF - (Respiratory Syncytial Virus (RSV) Prophylaxis)
  • TestosteroneOpen a PDF - Testosterone
  • Tremfya (Health Professional Administration)Open a PDF - (Psoriasis or Psoriatic Arthritis)
  • Tysabri (natalizumab)Open a PDF - (For Crohn's Disease)
  • Tysabri (natalizumab)Open a PDF - (For Crohns Disease (Recertification)
  • Tysabri (natalizumab)Open a PDF - (For Multiple Sclerosis)
  • VectibixOpen a PDF - (For Colorectal Cancer, Head & Neck, NSCLC)
  • Viscosupplementation with Hyaluronic AcidOpen a PDF - (Gel-One, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, TriVisc, Visco-3)
  • Xgeva (Healthcare Administration)Open a PDF - (Prevention of (SRE) Skeletal Related Events)
  • XolairOpen a PDF - (omalizumab)
  • Zaltrap (ziv-aflibercept) Open a PDF - (Metastatic Colorectal Cancer)
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