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Prior Authorization Forms for Specialty Drugs
A
Abilify
Actemra
Acthar Gel
Actimmune
Adcirca
Afinitor
Ampyra
Arcalyst llaris
Aubagio
Avonex, Betaseron, Extavia, Rebif
B
Berinert
Betaseron
Bosulif
C
Cimzia - Arthritis
Cimzia - IBD
Cimzia - Psoriasis
Copaxone
Copegus
E
Egrifta
Enbrel - Arthritis
Enbrel - Psoriasis
Erivedge
Extavia
F
Firazyr
Forteo
G
General PA Form
Genotropin - Adult
Genotropin - Pediatric
Gilenya
Gleevec
H
Hizentra
Humatrope - Adult
Humatrope - Pediatric
Humira - Arthritis
Humira - IBD
Humira - Psoriasis
I
Iclusig
Incivek
Increlex
Inlyta
J
Jakafi
K
Kalydeco
Kineret
Kuvan
Kynamro
L
Letairis
M
Mitoxantron
Moderiba
Mozobil
N
Nexavar
Norditropin - Adult
Norditropin - Pediatric
Nplate
Nutropin AQ - Adult
Nutropin AQ - Pediatric
O
Olysio
Omnitrope - Adult
Omnitrope - Pediatric
Onasemnogene abeparvovec (Zolgensma)
Orencia
P
Pegasys
Peg-Intron
R
Rebetol
Rebif
Remicade - Arthritis
Remicade - IBD
Remicade - Psoriasis
Revatio
Revlimid
Ribapak
Ribasphere
Ribatab
Ribavirin
Rituxan
S
Sabril
Saizen - Adult
Saizen - Pediatric
Sildenafil
Simponi
Sovaldi
Sprycel
Stelara
Stivarga
Sutent
T
Tafinlar
Tarceva
Tasigna
Tecfidera
Tev-Tropin - Adult
Tev-Tropin - Pediatric
Thalomid
Tykerb
Tysabri
V
Victrelis
Votrient
X
Xalkori
Xeljanz
Xenazine
Xtandi
Z
Zolinza
Zytiga