Drug-Specific Pharmacy Prior Authorizations
Medicare Advantage

Drugs listed on this page require prior authorization under the Pharmacy benefit for Medicare Advantage.

If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Using the appropriate form will help to ensure that we have the information necessary to make a decision about your request.

Fax all completed prior authorization request forms to the Pharmacy department at 1-866-371-3239.

Pharmacy Prescription Drug Coverage Determination Request Form

Please note that there are different prior authorization forms for Medicaid, CHIP and Individual and Family Plans. To access those forms, visit the Medicaid and CHIP and the IFP pages.