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Prior Authorization & Coverage Exception Forms
Prior Auth Form
Prior Auth Criteria
1. Afinitor
2. Erythrocyte Stim. Agents
3. Fentanyl Citrate Lollipop
4. Forteo
5. Growth Hormone
6. Kuvan
7. Novarel
8. Pegasys Peg-Intron
9. Promacta
10. Provigil
11. Rebetol - Ribavirin
12. Retin-A
13. Revatio
14. Revlimid
15. Saphris
16. Tazorac
17. Thalomid
18. Tracleer
19. Tysabri
20. Votrient
21. Xenazine
22. Xolair
Coverage Exception Request Form - PDF
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