Prescription Drug Authorization Forms — Employer Plans, Individual & Family Plans, and FAMIS
If you need any assistance or have questions about the drug authorization forms please contact the Sentara Health Plans Pharmacy team by calling 800-229-5522.
Pharmacy General Exception Forms
Delegated Roster Template
XLSX, 16 MB
XLSX, 16 MB
Maximum Daily Dosage Limit Exceptions Request Form
PDF, 164 KB
PDF, 164 KB
Medical Drug Authorization Changes
Medical Drug Authorization Changes
PDF, 143 KB
PDF, 143 KB
OB Registration Form
PDF, 241 KB
PDF, 241 KB
Pancreatic Enzyme Utilization Criteria for Cystic Fibrosis
PDF, 29 KB
PDF, 29 KB
Pharmacy Benefit Oncology Medications
PDF, 180 KB
PDF, 180 KB
Pharmacy Medical Necessity Request Form
PDF, 148 KB
PDF, 148 KB
Roster Template_11012023
XLSX, 17 MB
XLSX, 17 MB
Drug Authorization Forms
Abecma (Medical)
PDF, 248 KB
PDF, 248 KB
Abrysvo (Medical)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 140 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 140 KB
Abrysvo (RSV Vaccine)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 122 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 122 KB
Actemra (diagnosis of Giant Cell Arteritis)
PDF, 215 KB
PDF, 215 KB
Actemra (diagnosis of Systemic Sclerosis-associated Interstitial Lung Disease)
PDF, 214 KB
PDF, 214 KB
Actemra IV (Medical)
PDF, 231 KB
PDF, 231 KB
Actemra IV for diagnosis of Cytokine Release Syndrome (CRS) (Medical)
PDF, 217 KB
PDF, 217 KB
Actemra SQ (Pharmacy) (Non-Preferred)
PDF, 195 KB
PDF, 195 KB
Actimmune (Medical)
PDF, 171 KB
PDF, 171 KB
ActimmuneSQ
PDF, 195 KB
PDF, 195 KB
Adakveo (Medical)
PDF, 203 KB
PDF, 203 KB
Adalimumab (Preferred) Products
(Cyltezo | Humira | Hyrimoz)
PDF, 235 KB
(Cyltezo | Humira | Hyrimoz)
PDF, 235 KB
Adbry
PDF, 254 KB
PDF, 254 KB
Addyi
PDF, 153 KB
PDF, 153 KB
adefovir dipivoxil (ADV, generic Hepsera)
PDF, 190 KB
PDF, 190 KB
Adstiladrin (Medical)
PDF, 223 KB
PDF, 223 KB
Aduhelm (Medical)
PDF, 359 KB
PDF, 359 KB
Afrezza
PDF, 159 KB
PDF, 159 KB
Albuterol Inhalers (Non-Preferred)
(albuterol HFA (generic ProAir HFA) | albuterol HFA (generic Proventil HFA) | albuterol HFA (generic Ventolin HFA) | levalbuterol HFA (generic Xopenex) | ProAir Digihaler/HFA/Respiclick | Proventil HFA)PDF, 161 KB
(albuterol HFA (generic ProAir HFA) | albuterol HFA (generic Proventil HFA) | albuterol HFA (generic Ventolin HFA) | levalbuterol HFA (generic Xopenex) | ProAir Digihaler/HFA/Respiclick | Proventil HFA)PDF, 161 KB
Aldurazyme (Medical)
PDF, 241 KB
PDF, 241 KB
Aliqopa IV (Medical)
PDF, 179 KB
PDF, 179 KB
alosetron (Lotronex) | Viberzi
PDF, 231 KB
PDF, 231 KB
Alpha Proteinase Inhibitors (Medical)
Aralast NP | Glassia | Prolastin-C | Zemaira
PDF, 209 KB
Aralast NP | Glassia | Prolastin-C | Zemaira
PDF, 209 KB
Amvuttra | Onpattro (Medical)
PDF, 264 KB
PDF, 264 KB
Anticonvulsants | Antiepileptic Drugs | Antiseizure Drugs
PDF, 230 KB
PDF, 230 KB
Antiparkinson Agents
Inbrija | Nourianz | Ongentys | tolcapone
PDF, 176 KB
Inbrija | Nourianz | Ongentys | tolcapone
PDF, 176 KB
Antipsychotics-Children (0-17) - COMMERCIAL ONLY
PDF, 187 KB
PDF, 187 KB
Aphexda (Medical)
PDF, 179 KB
PDF, 179 KB
Apokyn | apomorphine hydrochoride | Kynmobi
PDF, 174 KB
PDF, 174 KB
Arcalyst
PDF, 321 KB
PDF, 321 KB
arformoterol nebulizer solution (Brovana & ABA)
PDF, 149 KB
PDF, 149 KB
Arikayce
PDF, 183 KB
PDF, 183 KB
Aspirin 81 mg (ACA Copay Wavier)
PDF, 141 KB
PDF, 141 KB
Atypical Antipsychotics
(asenapine | Caplyta | Fanapt | lurasidone | paliperidone | Rexulti | Vraylar)
PDF, 163 KB
(asenapine | Caplyta | Fanapt | lurasidone | paliperidone | Rexulti | Vraylar)
PDF, 163 KB
Austedo
PDF, 178 KB
PDF, 178 KB
Auvelity ER
PDF, 161 KB
PDF, 161 KB
Auvi-Q Auto-Injector
PDF, 162 KB
PDF, 162 KB
Aveed | TestoPel (Medical) (Testosterone Replacement Therapy will be purchased by physician's office)
PDF, 223 KB
PDF, 223 KB
Azedra (Medical)
PDF, 275 KB
PDF, 275 KB
Benlysta (Medical)
PDF, 201 KB
PDF, 201 KB
Benlysta (Pharmacy)
PDF, 292 KB
PDF, 292 KB
Berinert IV (Medical)
PDF, 214 KB
PDF, 214 KB
Besponsa IV (Medical)
PDF, 212 KB
PDF, 212 KB
Beyfortus (Medical)
PDF, 199 KB
PDF, 199 KB
Bimzelx
PDF, 163 KB
PDF, 163 KB
Botox | Xeomin (Medical)
Botulinum Toxin Injections, Type A (Botox | Xeomin)
PDF, 195 KB
Botulinum Toxin Injections, Type A (Botox | Xeomin)
PDF, 195 KB
Botox Injections-Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS)) (Medical)
Botulinum Toxin Injections, Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS))
PDF, 171 KB
Botulinum Toxin Injections, Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS))
PDF, 171 KB
Botox Injection-Type A (Chronic Migraine Headache Prophylaxis) (Medical)
Botulinum Toxin Injections, Type A (Chronic Migraine Headache Prophylaxis)
PDF, 235 KB
Botulinum Toxin Injections, Type A (Chronic Migraine Headache Prophylaxis)
PDF, 235 KB
Botox Injection-Type A (Hyperhidrosis) (Medical)
Botulinum Toxin Injections, Type A (Hyperhidrosis)
PDF, 207 KB
Botulinum Toxin Injections, Type A (Hyperhidrosis)
PDF, 207 KB
Breast Cancer Prevention Drugs
PDF, 139 KB
PDF, 139 KB
Brexafemme
PDF, 178 KB
PDF, 178 KB
Breyanzi (Medical)
PDF, 247 KB
PDF, 247 KB
Brineura IV (Medical)
PDF, 210 KB
PDF, 210 KB
Briumvi (Medical)
PDF, 218 KB
PDF, 218 KB
Brixadi│Sublocade
PDF, 184 KB
PDF, 184 KB
Brixadi│Sublocade (Medical)
PDF, 181 KB
PDF, 181 KB
Bronchitol
PDF, 210 KB
PDF, 210 KB
butorphanol (Stadol) Nasal Spray
PDF, 150 KB
PDF, 150 KB
Bylvay
PDF, 230 KB
PDF, 230 KB
Cabenuva LAP (Medical)
PDF, 164 KB
PDF, 164 KB
Cabenuva LAP (Pharmacy)
PDF, 156 KB
PDF, 156 KB
Cablivi
PDF, 222 KB
PDF, 222 KB
Camzyos
PDF, 139 KB
PDF, 139 KB
candesartan (Atacand) | candesartan-HCTZ (Atacand HCT) | Edarbi | Edarbyclor | aliskiren (Tekturna) | Tekturna HCT
PDF, 213 KB
PDF, 213 KB
carglumic acid (Carbaglu)
PDF, 199 KB
PDF, 199 KB
Carvykti (Medical)
PDF, 266 KB
PDF, 266 KB
Casgevy (Medical)
PDF, 279 KB
PDF, 279 KB
Central Nervous System (CNS) Stimulants (Age 19 and Above)
(Adhansia XR | Adzenys XR-ODT/ER | amphetamine/dextroamphetamine (Adderall) |amphetamine/dextroamphetamine ER (Adderall XR) | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR/ODT | dexmethylphenidate (Focalin) | dexmethylphenidate ER (Focalin XR) | dextroamphetamine (Zenzedi) | dextroamphetamine (ProCentra) | dextroamphetamine (Dextrostat) | dextroamphetamine ER (Dexedrine Spansule) | Dyanavel XR | Evekeo ODT | Jornay PM | methamphetamine (Desoxyn) | methylphenidate ER (Aptensio XR) | methylphenidate ER (Concerta) | methylphenidate TID Patch (Daytrana) | methylphenidate ER (Ritalin SR/Metadate ER) | methylphenidate (Ritalin/Methylin) | methylphenidate LA (Ritalin LA) | methylphenidate CD (Metadate CD) | Mydays | Quillichew ER | Quillivant XR | Vyvanse)
PDF, 182 KB
(Adhansia XR | Adzenys XR-ODT/ER | amphetamine/dextroamphetamine (Adderall) |amphetamine/dextroamphetamine ER (Adderall XR) | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR/ODT | dexmethylphenidate (Focalin) | dexmethylphenidate ER (Focalin XR) | dextroamphetamine (Zenzedi) | dextroamphetamine (ProCentra) | dextroamphetamine (Dextrostat) | dextroamphetamine ER (Dexedrine Spansule) | Dyanavel XR | Evekeo ODT | Jornay PM | methamphetamine (Desoxyn) | methylphenidate ER (Aptensio XR) | methylphenidate ER (Concerta) | methylphenidate TID Patch (Daytrana) | methylphenidate ER (Ritalin SR/Metadate ER) | methylphenidate (Ritalin/Methylin) | methylphenidate LA (Ritalin LA) | methylphenidate CD (Metadate CD) | Mydays | Quillichew ER | Quillivant XR | Vyvanse)
PDF, 182 KB
Central Nervous System (CNS) Stimulants (Non-Preferred)
(Adhansia XR | Adzenys XR-ODT | Adzenys ER Susp | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR-ODT | Dyanavel XR | Evekeo ODT | Jornay PM | methylphenidate ER (Aptensio XR) | methylphenidate TD Patch (Daytrana) | Mydayis | Quillichew ER | Quillivant XR)
PDF, 170 KB
(Adhansia XR | Adzenys XR-ODT | Adzenys ER Susp | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR-ODT | Dyanavel XR | Evekeo ODT | Jornay PM | methylphenidate ER (Aptensio XR) | methylphenidate TD Patch (Daytrana) | Mydayis | Quillichew ER | Quillivant XR)
PDF, 170 KB
Cholbam
PDF, 188 KB
PDF, 188 KB
Cibinqo
PDF, 193 KB
PDF, 193 KB
Cimzia Lyophilized IV (Medical)
PDF, 191 KB
PDF, 191 KB
Cimzia SQ (Pharmacy benefit Prefilled syringe)
PDF, 205 KB
PDF, 205 KB
cinacalcet (Sensipar)
PDF, 198 KB
PDF, 198 KB
Cinqair IV (Medical)
PDF, 169 KB
PDF, 169 KB
Compound Drugs
PDF, 139 KB
PDF, 139 KB
Continuous Glucose Monitors (CGM) & Subcutaneous Insulin Pumps (Group Specific Benefit)
(PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)
PDF, 183 KB
(PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)
PDF, 183 KB
Corlanor
PDF, 181 KB
PDF, 181 KB
Cosentyx IV (Medical)
PDF, 218 KB
PDF, 218 KB
Cosentyx SQ (Pharmacy)
PDF, 214 KB
PDF, 214 KB
Cresemba (Medical)
PDF, 238 KB
PDF, 238 KB
Cresemba (Pharmacy)
PDF, 200 KB
PDF, 200 KB
Crinone
PDF, 152 KB
PDF, 152 KB
Crysvita Injection (Medical)
PDF, 212 KB
PDF, 212 KB
Cuvrior | Syprine | trientine
PDF, 187 KB
PDF, 187 KB
Cystaran | Cystadrops
PDF, 188 KB
PDF, 188 KB
Daxxify (Medical)
PDF, 166 KB
PDF, 166 KB
Daybue
PDF, 214 KB
PDF, 214 KB
deferasirox (Exjade) | deferasirox (Jadenu)
PDF, 183 KB
PDF, 183 KB
deferiprone tablets (Ferriprox) | Ferriprox solution
PDF, 186 KB
PDF, 186 KB
Depen Titratable tablets | Penicillamine tablets (PREFERRED) | Cuprimine | Penicillamine capsules (NON-PREFERRED)
PDF, 172 KB
PDF, 172 KB
Dextenza (Medical)
PDF, 221 KB
PDF, 221 KB
Diacomit
PDF, 155 KB
PDF, 155 KB
dichlorphenamide (Keveyis)
PDF, 162 KB
PDF, 162 KB
Dificid
PDF, 219 KB
PDF, 219 KB
dihydroergotamine mesylate (D.H.E. 45) | dihydroergotamine mesylate (Migranal)
PDF, 157 KB
PDF, 157 KB
Dipetidyl Peptidase 4 (DPP4) Inhibitors
(alogliptin (Nesina ABA) | alogliptin-pioglitazone (Oseni ABA)| alogliptin-metformin (Kazano ABA)| Kazano | Nesina | Oseni | saxagliptin (Onglyza) | saxagliptin-metformin ER (Kombigliyze XR) | Zituvio)
PDF, 147 KB
(alogliptin (Nesina ABA) | alogliptin-pioglitazone (Oseni ABA)| alogliptin-metformin (Kazano ABA)| Kazano | Nesina | Oseni | saxagliptin (Onglyza) | saxagliptin-metformin ER (Kombigliyze XR) | Zituvio)
PDF, 147 KB
Dojolvi
PDF, 249 KB
PDF, 249 KB
Doptelet
PDF, 207 KB
PDF, 207 KB
doxylamine-pyridoxine (Diclegis)
PDF, 153 KB
PDF, 153 KB
droxidopa (Northera)
PDF, 183 KB
PDF, 183 KB
Dry Eye Medications
(Cequa | Lacrisert | Miebo | Restasis Multidose | Tyrvaya)
PDF, 157 KB
(Cequa | Lacrisert | Miebo | Restasis Multidose | Tyrvaya)
PDF, 157 KB
Duavee
PDF, 159 KB
PDF, 159 KB
Duchenne Muscular Dystrophy Medications (Medical)
(Amondys 45 | Exondys 51 | Viltepso | Vyondys 53)
PDF, 171 KB
(Amondys 45 | Exondys 51 | Viltepso | Vyondys 53)
PDF, 171 KB
Dupixent
PDF, 266 KB
PDF, 266 KB
Durysta (Medical)
PDF, 171 KB
PDF, 171 KB
Dysport (Botox Injections) (Medical) (Cosmetic indications Excluded)
PDF, 219 KB
PDF, 219 KB
Egrifta
PDF, 155 KB
PDF, 155 KB
Elaprase IV (Medical)
PDF, 233 KB
PDF, 233 KB
Elevidys (Medical)
PDF, 172 KB
PDF, 172 KB
Elfabrio IV (Medical)
(IV Infusion)
PDF, 225 KB
(IV Infusion)
PDF, 225 KB
Emflaza
PDF, 245 KB
PDF, 245 KB
Empaveli (Medical)
PDF, 203 KB
PDF, 203 KB
Emsam
PDF, 140 KB
PDF, 140 KB
Emverm
PDF, 196 KB
PDF, 196 KB
Enbrel
PDF, 201 KB
PDF, 201 KB
Endari
PDF, 161 KB
PDF, 161 KB
Enjaymo (Medical)
PDF, 248 KB
PDF, 248 KB
Enspryng
PDF, 149 KB
PDF, 149 KB
Entyvio (Pharmacy)
PDF, 179 KB
PDF, 179 KB
Entyvio IV (Medical)
PDF, 195 KB
PDF, 195 KB
Epidiolex
PDF, 184 KB
PDF, 184 KB
Erectile Dysfunction
(Stendra | vardenafil (Levitra))
PDF, 146 KB
(Stendra | vardenafil (Levitra))
PDF, 146 KB
Erythropoiesis Stimulating Agents
Aranesp | Epogen | Mircera | Procrit | Retacrit
PDF, 227 KB
Aranesp | Epogen | Mircera | Procrit | Retacrit
PDF, 227 KB
ethacrynic acid (Edecrin)
PDF, 148 KB
PDF, 148 KB
Eucrisa
PDF, 194 KB
PDF, 194 KB
Evenity (Medical)
PDF, 218 KB
PDF, 218 KB
Evkeeza (Medical)
PDF, 226 KB
PDF, 226 KB
Evrysdi
PDF, 184 KB
PDF, 184 KB
Eylea - Retinopathy of Prematurity (ROP) (Medical)
PDF, 164 KB
PDF, 164 KB
ezetimibe-simvastatin (Vytorin)
PDF, 159 KB
PDF, 159 KB
Fabrazyme IV (Medical)
(IV Infusion)
PDF, 214 KB
(IV Infusion)
PDF, 214 KB
Fasenra SQ (Medical)
PDF, 202 KB
PDF, 202 KB
Fasenra SQ (Pharmacy)
PDF, 201 KB
PDF, 201 KB
Fetzima | Trintellix | vilazodone (Viibryd)
PDF, 143 KB
PDF, 143 KB
Filspari
PDF, 180 KB
PDF, 180 KB
Fintepla
PDF, 216 KB
PDF, 216 KB
Firdapse
PDF, 169 KB
PDF, 169 KB
Flector Patch
PDF, 142 KB
PDF, 142 KB
flucytosine (Ancobon)
PDF, 152 KB
PDF, 152 KB
Furoscix
PDF, 150 KB
PDF, 150 KB
Galafold
PDF, 169 KB
PDF, 169 KB
Gamifant IV (Medical)
(IV Infusion)
PDF, 253 KB
(IV Infusion)
PDF, 253 KB
Gastrointestinal Motility Drugs
(Ibsrela | Motegrity | Relistor | Trulance | Zelnorm)
PDF, 183 KB
(Ibsrela | Motegrity | Relistor | Trulance | Zelnorm)
PDF, 183 KB
Gattex
PDF, 258 KB
PDF, 258 KB
Gaucher Disease Drugs (Enzyme Replacement Therapy) (Medical)
(Cerezyme | Elelyso | Vpriv)
PDF, 213 KB
(Cerezyme | Elelyso | Vpriv)
PDF, 213 KB
Gaucher Disease Drugs (Substrate Reduction Therapy) (Pharmacy)
(Cerdelga | Miglustat)
PDF, 222 KB
(Cerdelga | Miglustat)
PDF, 222 KB
Givlaari (Medical)
PDF, 228 KB
PDF, 228 KB
Glaucoma Drugs
(Betimol | Betoptic-S | brimonidine 0.1% (Alphagan-P)| Rhopressa | Rocklatan | Simbrinza | tafluprost (Zioptan) | travoprost 0.004% (Travatan Z) | Vyzulta)
PDF, 143 KB
(Betimol | Betoptic-S | brimonidine 0.1% (Alphagan-P)| Rhopressa | Rocklatan | Simbrinza | tafluprost (Zioptan) | travoprost 0.004% (Travatan Z) | Vyzulta)
PDF, 143 KB
Glucagon Analogs
(GlucaGen HypoKit | Zegalogue)
PDF, 199 KB
(GlucaGen HypoKit | Zegalogue)
PDF, 199 KB
Glucagon-like peptide (GLP-1) receptor agonists
(Bydureon Bcise | Byetta | Mounjaro | Ozempic | Rybelsus | Trulicity | Victoza)
PDF, 168 KB
(Bydureon Bcise | Byetta | Mounjaro | Ozempic | Rybelsus | Trulicity | Victoza)
PDF, 168 KB
glycopyrrolate (Cuvposa)
PDF, 186 KB
PDF, 186 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Medical)
PDF, 267 KB
PDF, 267 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Pharmacy)
(PREFERRED: Eligard | Leuprolide | Lupron Depot | Lupron Depot-Ped | Trelstar | Zoladex) (NON-PREFERRED: (Fensolvi | Supprelin LA | Synarel | Triptodur)
PDF, 240 KB
(PREFERRED: Eligard | Leuprolide | Lupron Depot | Lupron Depot-Ped | Trelstar | Zoladex) (NON-PREFERRED: (Fensolvi | Supprelin LA | Synarel | Triptodur)
PDF, 240 KB
Graft-Versus-Host Disease (GVHD) Drugs
(Jakafi | Imbruvica)
PDF, 215 KB
(Jakafi | Imbruvica)
PDF, 215 KB
Granulocyte Colony-Stimulating Factors (G-CSFs) (GM-CSF) (G-CSFs)
G-CSFs: (Granix | Neupogen | Nivestym | Releuko | Zarxio) GM-CSF: (Leukine) G-CSFs: (Fulphila | Fylnetra | Neulasta | Nyvepria | Rolvedon | Stimufend | Udenyca | Ziextenzo)
PDF, 199 KB
G-CSFs: (Granix | Neupogen | Nivestym | Releuko | Zarxio) GM-CSF: (Leukine) G-CSFs: (Fulphila | Fylnetra | Neulasta | Nyvepria | Rolvedon | Stimufend | Udenyca | Ziextenzo)
PDF, 199 KB
Grastek | Oralair
PDF, 171 KB
PDF, 171 KB
Hemangeol
PDF, 159 KB
PDF, 159 KB
Hemgenix (Medical)
PDF, 266 KB
PDF, 266 KB
Hemophilia Factors (IV) (Medical)
PDF, 166 KB
PDF, 166 KB
Hepatitis-C Antiviral (HCV) Drugs
(PREFERRED: sofosbuvir/elpatasvir | ledipasvir/sofobuvir | Mavyret) (NON-PREFERRED: Epclusa | Harvoni | Sovaldi | Viekira Pak | Vosevi | Zepatier)
PDF, 244 KB
(PREFERRED: sofosbuvir/elpatasvir | ledipasvir/sofobuvir | Mavyret) (NON-PREFERRED: Epclusa | Harvoni | Sovaldi | Viekira Pak | Vosevi | Zepatier)
PDF, 244 KB
High Dose Statins (ACA Copay Wavier)
PDF, 171 KB
PDF, 171 KB
Hyaluronate Acids (Medical)
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 244 KB
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 244 KB
ibuprofen-famotidine (Duexis) | naproxen-esomeprazole magnesium (Vimovo)
PDF, 194 KB
PDF, 194 KB
icatibant (Firazyr) | sajazir (Firazyr) (Medical)
PDF, 204 KB
PDF, 204 KB
icatibant (Firazyr) | sajazir (Firazyr) (Pharmacy)
PDF, 222 KB
PDF, 222 KB
icosapent ethyl (Vascepa)
PDF, 200 KB
PDF, 200 KB
Ilaris (sJIA | AOSD) (Medical) (Non-Preferred)
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA) OR Adult Onset Still's Disease (AOSD)
PDF, 281 KB
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA) OR Adult Onset Still's Disease (AOSD)
PDF, 281 KB
Ilaris (TRAPS | HIDS/MKD | FMF diseases | CAPS) (Medical)
This form is applicable for the following diagnoses: Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF) and Cryopyrin-Associated Periodic Syndromes (CAPS)
PDF, 241 KB
This form is applicable for the following diagnoses: Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF) and Cryopyrin-Associated Periodic Syndromes (CAPS)
PDF, 241 KB
Ilumya (Pharmacy)
PDF, 164 KB
PDF, 164 KB
Ilumya SQ (Medical)
(Ilumya should ONLY be administered by a healthcare provider)
PDF, 172 KB
(Ilumya should ONLY be administered by a healthcare provider)
PDF, 172 KB
Imcivree
PDF, 207 KB
PDF, 207 KB
Imlygic (Medical)
PDF, 202 KB
PDF, 202 KB
Immune Globulin Intravenous (IVIG) (immunodeficiency) (CIDP) (Medical)
(Chronic Inflammatory Demyelinating Polyneuropathy)
PDF, 231 KB
(Chronic Inflammatory Demyelinating Polyneuropathy)
PDF, 231 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Disorders) (Medical)
(Miscellaneous Disorders)
PDF, 265 KB
(Miscellaneous Disorders)
PDF, 265 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Sjögren’s Syndrome Neuropathies) (Medical)
(Miscellaneous Sjögren’s Syndrome Neuropathies)
PDF, 265 KB
(Miscellaneous Sjögren’s Syndrome Neuropathies)
PDF, 265 KB
Immune Globulin Intravenous (IVIG) (Multifocal Motor Neuropathy (MMN)) (Medical)
(Multifocal Motor Neuropathy (MMN))
PDF, 218 KB
(Multifocal Motor Neuropathy (MMN))
PDF, 218 KB
Immune Globulin Intravenous (IVIG) (Primary Immunodeficiency Disorder (PID)) (Medical)
(Asceniv | Bivigam | Carimune NF | Flebogamma DIF | Gammagard | Gammaked | Gammaplex | Gamunex-C | Octagam | Panzyga | Privigen)
PDF, 238 KB
(Asceniv | Bivigam | Carimune NF | Flebogamma DIF | Gammagard | Gammaked | Gammaplex | Gamunex-C | Octagam | Panzyga | Privigen)
PDF, 238 KB
Immune Globulin SQ (Primary Immunodeficiency Disorder) (Medical)
(Cutaquiq | Cuvitru | Gammagard | Gammunex-C | Hizentra | Hyqvia | Xembify)
PDF, 247 KB
(Cutaquiq | Cuvitru | Gammagard | Gammunex-C | Hizentra | Hyqvia | Xembify)
PDF, 247 KB
Increlex
PDF, 176 KB
PDF, 176 KB
Infertility Drugs
(cetrotide| Crinone | Follistim | Gonal-F | Novarel | clomiphene citrate | Endometrin | Fyremadel | Ovidrel | chorionic gonadotropin | First-progesterone vaginal suppository | ganirelix acetate | Menopur | Pregnyl)
PDF, 140 KB
(cetrotide| Crinone | Follistim | Gonal-F | Novarel | clomiphene citrate | Endometrin | Fyremadel | Ovidrel | chorionic gonadotropin | First-progesterone vaginal suppository | ganirelix acetate | Menopur | Pregnyl)
PDF, 140 KB
Infliximab Category (Medical)
(PREFERRED: Renflexis) (Non-Preferred: Avsola | Inflectra | infliximab | Remicade)
PDF, 237 KB
(PREFERRED: Renflexis) (Non-Preferred: Avsola | Inflectra | infliximab | Remicade)
PDF, 237 KB
Ingrezza
PDF, 175 KB
PDF, 175 KB
Injectable Migraine Treatment (CGRP)
Injectable Calcitonin Gene-Related Peptide (CGRP) Antagonists (PREFERRED: Aimovig l Emgality) (NON-PREFERRED: Ajovy)
PDF, 194 KB
Injectable Calcitonin Gene-Related Peptide (CGRP) Antagonists (PREFERRED: Aimovig l Emgality) (NON-PREFERRED: Ajovy)
PDF, 194 KB
Inpefa
PDF, 145 KB
PDF, 145 KB
Insomnia Drugs
(Belsomra | Dayvigo |doxepin | quazepam (Doral) | Quviviq | ramelteon (Rozerem))PDF, 161 KB
(Belsomra | Dayvigo |doxepin | quazepam (Doral) | Quviviq | ramelteon (Rozerem))PDF, 161 KB
Insulins (Non-Preferred)
(NON-PREFERRED: Admelog | Apidra | Basaglar | Fiasp | insulin aspart | insulin aspart protamine 70/30 | insulin degludec | insulin glargine vial/SoloStar | insulin glargine Solostar/Max Solostar | insulin lispro | insulin lispro JR | insulin lispro 75/25 mix Kwikpen | Levemir | Lyumjev | Novolin 70/30 | Novolin N | Novolin R | Novolog | NovoLOG Mix 70/30 | Semglee )
PDF, 174 KB
(NON-PREFERRED: Admelog | Apidra | Basaglar | Fiasp | insulin aspart | insulin aspart protamine 70/30 | insulin degludec | insulin glargine vial/SoloStar | insulin glargine Solostar/Max Solostar | insulin lispro | insulin lispro JR | insulin lispro 75/25 mix Kwikpen | Levemir | Lyumjev | Novolin 70/30 | Novolin N | Novolin R | Novolog | NovoLOG Mix 70/30 | Semglee )
PDF, 174 KB
Intravitreal Complement Inhibitors
(Izervay | Syfovre)
PDF, 210 KB
(Izervay | Syfovre)
PDF, 210 KB
Irritable Bowel Disease (IBD) Non-Preferred
(Mesalamine DR 800 mg | Dipentum | budesonide ER 9mg | Uceris) (Non-Preferred Commercial Only)
PDF, 162 KB
(Mesalamine DR 800 mg | Dipentum | budesonide ER 9mg | Uceris) (Non-Preferred Commercial Only)
PDF, 162 KB
Isturisa
PDF, 192 KB
PDF, 192 KB
Ivermectin (Stromectol) tablets
PDF, 128 KB
PDF, 128 KB
Jesduvroq (Medical)
PDF, 176 KB
PDF, 176 KB
Joenja
PDF, 179 KB
PDF, 179 KB
Juxtapid
PDF, 179 KB
PDF, 179 KB
Jynarque
PDF, 282 KB
PDF, 282 KB
Kalbitor (Medical)
PDF, 213 KB
PDF, 213 KB
Kalydeco
PDF, 177 KB
PDF, 177 KB
Kanuma (Medical)
PDF, 214 KB
PDF, 214 KB
Kerendia
PDF, 175 KB
PDF, 175 KB
Kevzara
PDF, 172 KB
PDF, 172 KB
Kineret
PDF, 244 KB
PDF, 244 KB
Korlym
PDF, 168 KB
PDF, 168 KB
Korsuva (Medical)
PDF, 200 KB
PDF, 200 KB
Koselugo
PDF, 198 KB
PDF, 198 KB
Krystexxa (Medical)
PDF, 248 KB
PDF, 248 KB
Kuvan
PDF, 178 KB
PDF, 178 KB
Kymriah (Medical)
PDF, 251 KB
PDF, 251 KB
Lampit | benznidazole
PDF, 172 KB
PDF, 172 KB
Lamzede (Medical)
PDF, 184 KB
PDF, 184 KB
Lantidra (Medical)
PDF, 200 KB
PDF, 200 KB
Lemtrada IV (Medical)
PDF, 171 KB
PDF, 171 KB
Leqembi (Medical)
PDF, 671 KB
PDF, 671 KB
Leqvio (Medical)
PDF, 258 KB
PDF, 258 KB
Litfulo
PDF, 163 KB
PDF, 163 KB
Livmarli
PDF, 176 KB
PDF, 176 KB
Livtencity
PDF, 253 KB
PDF, 253 KB
Lodoco
PDF, 171 KB
PDF, 171 KB
Long-Acting Antimuscarinic (LAMA) and Long-Acting Beta2 Agonist (LABA) Combination Products
Bevespi Aerosphere | Breztri | Duaklir Pressair
PDF, 180 KB
Bevespi Aerosphere | Breztri | Duaklir Pressair
PDF, 180 KB
Long-Acting Beta2 Agonist (LABA) and Inhaled Corticosteroid (ICS) Combination Products
Advair Diskus | AirDuo Digihaler | AirDuo RespiClick | fluticasone furoate-vilanterol | Symbicort
PDF, 166 KB
Advair Diskus | AirDuo Digihaler | AirDuo RespiClick | fluticasone furoate-vilanterol | Symbicort
PDF, 166 KB
Long-Acting Muscarinic Antagonist (LAMA) Anticholinergic Inhalers
Lonhala Magnair | Tudorza Pressair | Yupelri
PDF, 182 KB
Lonhala Magnair | Tudorza Pressair | Yupelri
PDF, 182 KB
Lumizyme (Medical)
PDF, 196 KB
PDF, 196 KB
Lupkynis
PDF, 197 KB
PDF, 197 KB
Lutathera (Medical)
PDF, 254 KB
PDF, 254 KB
Luxturna (Medical)
(Medication should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in intraocular surgery.)
PDF, 155 KB
(Medication should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in intraocular surgery.)
PDF, 155 KB
Lyfgenia (Medical)
PDF, 290 KB
PDF, 290 KB
Lyrica CR
PDF, 166 KB
PDF, 166 KB
Macular Degeneration Drugs (Medical)
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Lucentis | Susvimo | Vabysmo)
PDF, 236 KB
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Lucentis | Susvimo | Vabysmo)
PDF, 236 KB
Marplan
PDF, 136 KB
PDF, 136 KB
Mepsevii IV (Medical)
PDF, 177 KB
PDF, 177 KB
mifepristone 200 mg (Mifeprex)
PDF, 149 KB
PDF, 149 KB
mifepristone 300 mg (Korlym)
PDF, 169 KB
PDF, 169 KB
Mometasone Sinus Implants (Medical)
(Propel | Sinuva)
PDF, 171 KB
(Propel | Sinuva)
PDF, 171 KB
Mulpleta
PDF, 167 KB
PDF, 167 KB
Multiple Sclerosis Drugs
(Bafiertam | Extavia | Gilenya 0.5mg | Kesimpta | Mavenclad | Mayzent | Ponvory | Vumerity | Zeposia)
PDF, 200 KB
(Bafiertam | Extavia | Gilenya 0.5mg | Kesimpta | Mavenclad | Mayzent | Ponvory | Vumerity | Zeposia)
PDF, 200 KB
Myalept
PDF, 174 KB
PDF, 174 KB
Myfembree | Oriahnn
PDF, 166 KB
PDF, 166 KB
Myobloc (Medical)
Botulinum Toxin Injections, Type B (Myobloc) (Cosmetic indications Excluded)
PDF, 168 KB
Botulinum Toxin Injections, Type B (Myobloc) (Cosmetic indications Excluded)
PDF, 168 KB
Mytesi (formerly FULYZAQ)
PDF, 173 KB
PDF, 173 KB
Naglazyme (Medical)
PDF, 201 KB
PDF, 201 KB
Nasal Corticosteroids
(azelastine HCl-fluticasone propionate (Dymista) | Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)
PDF, 184 KB
(azelastine HCl-fluticasone propionate (Dymista) | Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)
PDF, 184 KB
Natpara
PDF, 172 KB
PDF, 172 KB
Nayzilam | Valtoco
PDF, 160 KB
PDF, 160 KB
Neupro
PDF, 143 KB
PDF, 143 KB
Nexletol | Nexlizet
PDF, 207 KB
PDF, 207 KB
Nexviazyme | Pombiliti (Medical)
PDF, 255 KB
PDF, 255 KB
nitazoxanide (Alinia)
PDF, 151 KB
PDF, 151 KB
Nocdurna
PDF, 156 KB
PDF, 156 KB
Noninfectious Uveitis (NIU) Drugs (Medical)
(Retisert | Yutiq)
PDF, 232 KB
(Retisert | Yutiq)
PDF, 232 KB
Non-Injectable Migraine Treatment
(PREFERRED: Nurtec ODT | Qulipta) (Non-Preferred: Reyvow | Ubrelvy | Zavzpret)
PDF, 208 KB
(PREFERRED: Nurtec ODT | Qulipta) (Non-Preferred: Reyvow | Ubrelvy | Zavzpret)
PDF, 208 KB
Non-Preferred inhaled Corticosteroids (ICS)
(Alvesco | ArmonAir Digihaler | Asmanex | Flovent Diskus/HFA | fluticasone propionate Diskus/HFA)
PDF, 166 KB
(Alvesco | ArmonAir Digihaler | Asmanex | Flovent Diskus/HFA | fluticasone propionate Diskus/HFA)
PDF, 166 KB
Novarel | Pregnyl | Ovidrel | chorionic gonadotropin
PDF, 191 KB
PDF, 191 KB
Nplate (Medical)
PDF, 245 KB
PDF, 245 KB
Nucala - Chronic Rhinosinusitis with Nasal Polyps (CRSWNP) (Medical)
PDF, 196 KB
PDF, 196 KB
Nucala - Chronic Rhinosinusitis with Nasal Polyps (CRSWNP) (Pharmacy)
PDF, 194 KB
PDF, 194 KB
Nucala - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Medical)
PDF, 226 KB
PDF, 226 KB
Nucala - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Pharmacy)
PDF, 228 KB
PDF, 228 KB
Nucala - Hypereosinophilic Syndome (HES) (Pharmacy)
PDF, 209 KB
PDF, 209 KB
Nucala - Hypereosinophilic Syndrome (HES) (Medical)
PDF, 214 KB
PDF, 214 KB
Nucala - Severe Eosinophilic Asthma (SEA) (Medical)
PDF, 206 KB
PDF, 206 KB
Nucala - Severe Eosinophilic Asthma (SEA) (Pharmacy)
PDF, 244 KB
PDF, 244 KB
Nuedexta
PDF, 154 KB
PDF, 154 KB
Nulibry (Medical)
PDF, 243 KB
PDF, 243 KB
Nulibry (Pharmacy)
PDF, 234 KB
PDF, 234 KB
Nulojix (Medical)
PDF, 213 KB
PDF, 213 KB
Nuplazid
PDF, 198 KB
PDF, 198 KB
Ocaliva
PDF, 138 KB
PDF, 138 KB
Ocrevus (Medical)
PDF, 175 KB
PDF, 175 KB
Ocular Antihistamines
(Alocril | Alomide | bepotastine besilate 1.5% (Bepreve) | Lastacaft | Zerviate)
PDF, 136 KB
(Alocril | Alomide | bepotastine besilate 1.5% (Bepreve) | Lastacaft | Zerviate)
PDF, 136 KB
Odactra House Dust Mite Allergen Extract
PDF, 165 KB
PDF, 165 KB
OFEV
PDF, 253 KB
PDF, 253 KB
Olumiant
PDF, 172 KB
PDF, 172 KB
Omisirge (Medical)
PDF, 228 KB
PDF, 228 KB
Omvoh
PDF, 179 KB
PDF, 179 KB
Opfolda
PDF, 203 KB
PDF, 203 KB
Ophthalmic Corticosteroid Injections (Medical)
(Ozurdex | Iluvien | Xipere)
PDF, 232 KB
(Ozurdex | Iluvien | Xipere)
PDF, 232 KB
Opioids - Commercial Only
PDF, 232 KB
PDF, 232 KB
Opzelura
PDF, 146 KB
PDF, 146 KB
Oral Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
PDF, 152 KB
PDF, 152 KB
Oral Proton Pump Inhibitors (PPI) Drugs (Non-Preferred)
(dexlansoprazole | omeprazole/sodium bicarbonate | Voquezna)
PDF, 152 KB
(dexlansoprazole | omeprazole/sodium bicarbonate | Voquezna)
PDF, 152 KB
Orencia - Graft Versus Host Disease (GVHD) (Medical)
PDF, 189 KB
PDF, 189 KB
Orencia IV (Infusion only) (Medical)
PDF, 149 KB
PDF, 149 KB
Orencia SQ (Pharmacy)
PDF, 173 KB
PDF, 173 KB
Orfadin | Nityr | nitisinone
PDF, 163 KB
PDF, 163 KB
Orilissa
PDF, 164 KB
PDF, 164 KB
Orkambi
PDF, 193 KB
PDF, 193 KB
Osphena
PDF, 131 KB
PDF, 131 KB
Otezla
PDF, 176 KB
PDF, 176 KB
Otrexup | Rasuvo | Reditrex
PDF, 130 KB
PDF, 130 KB
Overactive Bladder Drugs
(Gemtesa | Myrbetriq | fesoterodine (Toviaz))
PDF, 161 KB
(Gemtesa | Myrbetriq | fesoterodine (Toviaz))
PDF, 161 KB
Oxbryta
PDF, 218 KB
PDF, 218 KB
Oxervate
PDF, 207 KB
PDF, 207 KB
Oxlumo
PDF, 165 KB
PDF, 165 KB
Oxlumo (Medical)
PDF, 181 KB
PDF, 181 KB
Palforzia
PDF, 201 KB
PDF, 201 KB
Palynziq Injection
PDF, 200 KB
PDF, 200 KB
Pancreatic Enzymes
(PREFERRED - Creon | Zenpep) (Non-Preferred - Pancreaze | Pertzye | Ultresa | Viokace)
PDF, 150 KB
(PREFERRED - Creon | Zenpep) (Non-Preferred - Pancreaze | Pertzye | Ultresa | Viokace)
PDF, 150 KB
Parathyroid Hormone Analogs
teriparatide (Forteo) | Tymlos | teriparatide
PDF, 180 KB
teriparatide (Forteo) | Tymlos | teriparatide
PDF, 180 KB
penciclovir (Denavir)
PDF, 153 KB
PDF, 153 KB
Phosphate Binders
Auryxia | lanthanum chewable tablet (Fosrenol) | Velphoro
PDF, 147 KB
Auryxia | lanthanum chewable tablet (Fosrenol) | Velphoro
PDF, 147 KB
pimecrolimus (Elidel)
PDF, 128 KB
PDF, 128 KB
pirfenidone (Esbriet)
PDF, 159 KB
PDF, 159 KB
pitavastatin (Livalo) | Zypitamag
PDF, 154 KB
PDF, 154 KB
plerixafor (Mozobil) (Medical)
PDF, 205 KB
PDF, 205 KB
Pluvicto (Medical)
PDF, 221 KB
PDF, 221 KB
posaconazole DR (Noxafil) tablets | Noxafil DR suspension
PDF, 242 KB
PDF, 242 KB
Potassium Binders
(Lokelma | Veltassa)
PDF, 167 KB
(Lokelma | Veltassa)
PDF, 167 KB
Pradaxa
PDF, 195 KB
PDF, 195 KB
Praluent | Repatha
PDF, 258 KB
PDF, 258 KB
Pretomanid
PDF, 162 KB
PDF, 162 KB
Prevymis (Tablets) (Pharmacy benefit)
PDF, 196 KB
PDF, 196 KB
Prevymis IV (Medical)
PDF, 216 KB
PDF, 216 KB
Prialt (Medical)
PDF, 143 KB
PDF, 143 KB
Procysbi
PDF, 167 KB
PDF, 167 KB
Promacta
PDF, 231 KB
PDF, 231 KB
Prophylaxis Hereditary Angiodema Drugs (Medical)
(Cinryze | Haegarda | Takhzyro)
PDF, 253 KB
(Cinryze | Haegarda | Takhzyro)
PDF, 253 KB
Prophylaxis Hereditary Angiodema Drugs (Pharmacy)
(Cinryze | Haegarda | Orladeyo | Takhzyro)
PDF, 204 KB
(Cinryze | Haegarda | Orladeyo | Takhzyro)
PDF, 204 KB
Pulmonary Arterial Hypertension Drugs (Medical)
(sildenafil IV | epoprostenol IV | treprostinil IV | Uptravi IV)
PDF, 247 KB
(sildenafil IV | epoprostenol IV | treprostinil IV | Uptravi IV)
PDF, 247 KB
Pulmonary Arterial Hypertension Drugs (Pharmacy)
(sildenafil 20mg | sildenafil oral suspension | tadalafil 20mg | Tadliq | ambrisentan | bosentan | Opsumit | Tracleer dispersible tablet | Adempas | Orenitram | Tyvaso | Tyvaso DPI | Uptravi | Ventavis)
PDF, 262 KB
(sildenafil 20mg | sildenafil oral suspension | tadalafil 20mg | Tadliq | ambrisentan | bosentan | Opsumit | Tracleer dispersible tablet | Adempas | Orenitram | Tyvaso | Tyvaso DPI | Uptravi | Ventavis)
PDF, 262 KB
Pulmozyme
PDF, 207 KB
PDF, 207 KB
Purified Cortrophin Gel | HP Acthar Gel (Infantile Spasms)
PDF, 164 KB
PDF, 164 KB
Purified Cortrophin Gel | HP Acthar Gel (Myositis)
PDF, 188 KB
PDF, 188 KB
Purified Cortrophin Gel | HP Acthar Gel (Nephrotic Syndrome)
PDF, 216 KB
PDF, 216 KB
Purified Cortrophin Gel | HP Acthar Gel (Ocular Diseases)
PDF, 226 KB
PDF, 226 KB
Purified Cortrophin Gel | HP Acthar Gel (Other Indications)
PDF, 193 KB
PDF, 193 KB
Purified Cortrophin Gel | HP Acthar Gel (Sarcoidosis)
PDF, 163 KB
PDF, 163 KB
Purified Cortrophin Gel | HP Acthar Gel (Systemic Lupus Erythematosus)
PDF, 217 KB
PDF, 217 KB
pyrimethamine (Daraprim)
PDF, 229 KB
PDF, 229 KB
Pyrukynd
PDF, 195 KB
PDF, 195 KB
Qalsody (Medical)
PDF, 212 KB
PDF, 212 KB
Qelbree
PDF, 153 KB
PDF, 153 KB
Radicava IV (Medical)
PDF, 234 KB
PDF, 234 KB
Radicava ORS
PDF, 196 KB
PDF, 196 KB
Ragwitek
PDF, 167 KB
PDF, 167 KB
Ravicti
PDF, 170 KB
PDF, 170 KB
Rayaldee
PDF, 195 KB
PDF, 195 KB
Reblozyl (Medical)
Applicable ICD-10 diagnosis Codes: D56.1, D56.5. For oncology-related diagnoses, please submit a prior authorization request is through the AIM ProviderPortal at www.providerportal.comPDF, 230 KB
Applicable ICD-10 diagnosis Codes: D56.1, D56.5. For oncology-related diagnoses, please submit a prior authorization request is through the AIM ProviderPortal at www.providerportal.comPDF, 230 KB
Rebyota (Medical)
PDF, 206 KB
PDF, 206 KB
Recombinant Growth Hormone (rhGH)
(PREFERRED: Omnitrope | Norditropin) (NON-PREFERRED: Genotropin | Humatrope | *Ngnela | Nutropin | Nutropin AQ | Saizen | Sogroya | *Skytrofa | Zomacton) (*For use in members < 18 years of age)
PDF, 181 KB
(PREFERRED: Omnitrope | Norditropin) (NON-PREFERRED: Genotropin | Humatrope | *Ngnela | Nutropin | Nutropin AQ | Saizen | Sogroya | *Skytrofa | Zomacton) (*For use in members < 18 years of age)
PDF, 181 KB
Recorlev
PDF, 193 KB
PDF, 193 KB
Relyvrio
PDF, 186 KB
PDF, 186 KB
Revcovi (Pharmacy)
PDF, 231 KB
PDF, 231 KB
Rezurock
PDF, 160 KB
PDF, 160 KB
Rezzayo (Medical)
PDF, 193 KB
PDF, 193 KB
Riabni | Rituxan IV | Ruxience | Truxima (Medical) (Non-Preferred)
PDF, 246 KB
PDF, 246 KB
Rinvoq
PDF, 223 KB
PDF, 223 KB
Rituxan Hycela IV (Medical)
(Medication provided by Physician's office)
PDF, 175 KB
(Medication provided by Physician's office)
PDF, 175 KB
Roctavian (Medical)
PDF, 221 KB
PDF, 221 KB
Ruconest (Pharmacy)
PDF, 231 KB
PDF, 231 KB
Rukobia
Ryplazim (Medical)
PDF, 223 KB
PDF, 223 KB
Rystiggo (Medical)
PDF, 185 KB
PDF, 185 KB
Sabril | Vigadrone | vigabatrin| Vigpoder
PDF, 175 KB
PDF, 175 KB
Saphnelo (Medical)
PDF, 235 KB
PDF, 235 KB
Savaysa
PDF, 173 KB
PDF, 173 KB
Savella
PDF, 154 KB
PDF, 154 KB
Scenesse (Medical)
PDF, 211 KB
PDF, 211 KB
Serostim
PDF, 162 KB
PDF, 162 KB
Seysara
PDF, 146 KB
PDF, 146 KB
Siliq Injection (Pharmacy)
PDF, 165 KB
PDF, 165 KB
Simponi ARIA IV (Medical) (Non-Preferred)
PDF, 223 KB
PDF, 223 KB
Simponi SQ (Pharmacy benefit only)
PDF, 172 KB
PDF, 172 KB
Sirturo
PDF, 167 KB
PDF, 167 KB
Skyclarys
PDF, 190 KB
PDF, 190 KB
Skyrizi - Crohn's Disease (CD) (Pharmacy)
PDF, 170 KB
PDF, 170 KB
Skyrizi - Plaque Psoriasis & Psoriatic Arthritis (PsO & PsA) (Pharmacy)
PDF, 142 KB
PDF, 142 KB
Skysona (Medical)
PDF, 222 KB
PDF, 222 KB
Sodium Oxybate Products
(Lumryz ER oral suspension | Sodium Oxybate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 224 KB
(Lumryz ER oral suspension | Sodium Oxybate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 224 KB
Sodium Phenylbutyrate Products
(sodium phenylbutyrate (Buphenyl) powder/tablets | Olpruva oral suspension | Pheburane oral suspension)
PDF, 187 KB
(sodium phenylbutyrate (Buphenyl) powder/tablets | Olpruva oral suspension | Pheburane oral suspension)
PDF, 187 KB
Sodium-glucose Cotransporter-2 Inhibitor (SGLT2) Drugs (Non-Preferred)
(Brenzavvy| Invokana | Invokamet/XR | Qtern | Segluromet | Steglatro | Steguljan|Segluromet)
PDF, 163 KB
(Brenzavvy| Invokana | Invokamet/XR | Qtern | Segluromet | Steglatro | Steguljan|Segluromet)
PDF, 163 KB
Sohonos
PDF, 173 KB
PDF, 173 KB
Soliqua | Xultophy
PDF, 161 KB
PDF, 161 KB
Soliris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
PDF, 229 KB
PDF, 229 KB
Soliris IV - Generalized Myasthenia Gravis (gMG) (Medical)
PDF, 232 KB
PDF, 232 KB
Soliris IV-Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)
PDF, 241 KB
PDF, 241 KB
Soliris IV-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
PDF, 247 KB
PDF, 247 KB
Somatostatin Analog Drugs (Medical)
(lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection | Somatuline Depot injection)
PDF, 164 KB
(lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection | Somatuline Depot injection)
PDF, 164 KB
Somatostatin Analog Drugs (Pharmacy)
(Bynfezia | Mycapssa | Sandostatin LAR Depot | Signafor | Somavert)
PDF, 207 KB
(Bynfezia | Mycapssa | Sandostatin LAR Depot | Signafor | Somavert)
PDF, 207 KB
Sotyktu
PDF, 174 KB
PDF, 174 KB
Spevigo (Medical)
PDF, 192 KB
PDF, 192 KB
Spinraza (Medical)
(Medication provided by Physician's office)
PDF, 273 KB
(Medication provided by Physician's office)
PDF, 273 KB
Spravato
PDF, 179 KB
PDF, 179 KB
Stelara - Crohn's Disease & Ulcerative Colitis (CD & UC) (Pharmacy)
PDF, 192 KB
PDF, 192 KB
Stelara - Plaque Psoriasis & Psoriatic Arthritis (PsO & PsA) (Pharmacy)
PDF, 175 KB
PDF, 175 KB
Strensiq
PDF, 205 KB
PDF, 205 KB
Sucraid
PDF, 168 KB
PDF, 168 KB
Sunlenca
PDF, 219 KB
PDF, 219 KB
Sunlenca (Medical)
PDF, 226 KB
PDF, 226 KB
Sunosi
PDF, 192 KB
PDF, 192 KB
Symdeko
PDF, 232 KB
PDF, 232 KB
Synagis
PDF, 894 KB
PDF, 894 KB
Syndros Oral Solution
PDF, 180 KB
PDF, 180 KB
tadalafil 2.5mg or 5mg (Benign Prostate Hyperplasia (BPH) ONLY)
PDF, 153 KB
PDF, 153 KB
Taltz SQ
PDF, 231 KB
PDF, 231 KB
Tarpeyo
PDF, 196 KB
PDF, 196 KB
tasimelteon (Hetlioz)
PDF, 200 KB
PDF, 200 KB
Tavalisse
PDF, 222 KB
PDF, 222 KB
Tavneos
PDF, 194 KB
PDF, 194 KB
Tecartus (Medical)
PDF, 247 KB
PDF, 247 KB
Tegsedi SQ Injection (Medical)
PDF, 199 KB
PDF, 199 KB
Tepezza (Medical)
PDF, 234 KB
PDF, 234 KB
Testosterone Replacement Therapy - TRT (Pharmacy)
(PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution | Kyzatrex) (NON-PREFERRED - Androderm | Natesto | Vogelxo 1%)
PDF, 219 KB
(PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution | Kyzatrex) (NON-PREFERRED - Androderm | Natesto | Vogelxo 1%)
PDF, 219 KB
tetrabenazine (Xenazine)
PDF, 154 KB
PDF, 154 KB
Tezspire (Medical)
PDF, 228 KB
PDF, 228 KB
Tezspire (Pharmacy)
PDF, 234 KB
PDF, 234 KB
Tiglutik
PDF, 162 KB
PDF, 162 KB
tiopronin (Thiola) | Thiola EC
PDF, 175 KB
PDF, 175 KB
Tobi Podhaler
PDF, 166 KB
PDF, 166 KB
tolvaptan (Samsca)
PDF, 166 KB
PDF, 166 KB
Topical Acne Drugs
(PREFERRED: adapalene (generic Differin) | tretinoin (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel | Altreno | Aklief | Amzeeq | Azelex | clindamycin1.2%/benzoyl peroxide 2.5% | dapsone gel 5% | Fabior | Retin-A Micro | tazarotene cream 0.1% | tretinoin gel 0.05% | tretinoin microsphere | Winlevi)
PDF, 153 KB
(PREFERRED: adapalene (generic Differin) | tretinoin (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel | Altreno | Aklief | Amzeeq | Azelex | clindamycin1.2%/benzoyl peroxide 2.5% | dapsone gel 5% | Fabior | Retin-A Micro | tazarotene cream 0.1% | tretinoin gel 0.05% | tretinoin microsphere | Winlevi)
PDF, 153 KB
Topical Antibiotics
(Altabax 1% ointment | Xepi 1% cream)
PDF, 138 KB
(Altabax 1% ointment | Xepi 1% cream)
PDF, 138 KB
Topical Antifungals
(Ertaczo | luliconazole (Luzu) | Mentax | naftifine (Naftin) | oxiconazole (Oxistat) | sulconazole (Exelderm))
PDF, 148 KB
(Ertaczo | luliconazole (Luzu) | Mentax | naftifine (Naftin) | oxiconazole (Oxistat) | sulconazole (Exelderm))
PDF, 148 KB
Topical Corticosteroids
(amcinonide 0.1% | betamethasone valerate 0.12% foam | calcipotriene/betamethasone | Capex Shampoo | clobetasol proprionate | clocortolone pivalate | Cordran Tape | dexoximetasone 0.05% and 0.25% | diflorasone 0.05% | fluocinonide 0.1% cream | flurandrenolide 0.05% | fluticasone 0.05% | Impoyz | Texacort | triamcinolone spray)
PDF, 176 KB
(amcinonide 0.1% | betamethasone valerate 0.12% foam | calcipotriene/betamethasone | Capex Shampoo | clobetasol proprionate | clocortolone pivalate | Cordran Tape | dexoximetasone 0.05% and 0.25% | diflorasone 0.05% | fluocinonide 0.1% cream | flurandrenolide 0.05% | fluticasone 0.05% | Impoyz | Texacort | triamcinolone spray)
PDF, 176 KB
Topical Immunomodulators
(Zyclara | imiquimod 3.75% packets/pump | Picato | Klisyri)
PDF, 180 KB
(Zyclara | imiquimod 3.75% packets/pump | Picato | Klisyri)
PDF, 180 KB
Topical Psoriasis Medications
(Vtama | Zoryve)
PDF, 182 KB
(Vtama | Zoryve)
PDF, 182 KB
Topical Rosacea Drugs
(brimonidine (Mirvaso) | Rhofade | ivermectin (Soolantra) | Zilxi)
PDF, 164 KB
(brimonidine (Mirvaso) | Rhofade | ivermectin (Soolantra) | Zilxi)
PDF, 164 KB
Tremfya
PDF, 142 KB
PDF, 142 KB
Trikafta
PDF, 199 KB
PDF, 199 KB
Trogarzo IV (Medical)
(Medication will be provided by the Physician's office.)
PDF, 165 KB
(Medication will be provided by the Physician's office.)
PDF, 165 KB
Tysabri IV (Medical)
PDF, 206 KB
PDF, 206 KB
Tyvaso (PH-ILD)
PDF, 197 KB
PDF, 197 KB
Tzield (Medical)
PDF, 251 KB
PDF, 251 KB
Uloric
PDF, 133 KB
PDF, 133 KB
Ultomiris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
PDF, 237 KB
PDF, 237 KB
Ultomiris IV - Generalized Myasthenia Gravis (gMG) (Medical)
PDF, 236 KB
PDF, 236 KB
Ultomiris IV-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
PDF, 241 KB
PDF, 241 KB
Uplinza (Medical)
PDF, 226 KB
PDF, 226 KB
Upneeq
PDF, 208 KB
PDF, 208 KB
Vecamyl
PDF, 149 KB
PDF, 149 KB
Velsipity
PDF, 164 KB
PDF, 164 KB
Vemlidy
PDF, 175 KB
PDF, 175 KB
Veopoz (Medical)
PDF, 218 KB
PDF, 218 KB
Veozah
PDF, 156 KB
PDF, 156 KB
Verquvo
PDF, 159 KB
PDF, 159 KB
Vijoice
PDF, 189 KB
PDF, 189 KB
Vimizim IV (Medical)
(IV Infusion performed ONLY at Sentara Infusion Centers.)
PDF, 216 KB
(IV Infusion performed ONLY at Sentara Infusion Centers.)
PDF, 216 KB
Visudyne (Medical)
PDF, 190 KB
PDF, 190 KB
Vivjoa
PDF, 227 KB
PDF, 227 KB
Vowst
PDF, 200 KB
PDF, 200 KB
Voxzogo
PDF, 196 KB
PDF, 196 KB
Vyepti (Medical)
PDF, 188 KB
PDF, 188 KB
Vyjuvek (Medical)
PDF, 225 KB
PDF, 225 KB
Vyleesi
PDF, 154 KB
PDF, 154 KB
Vyndaqel | Vyndamax
PDF, 186 KB
PDF, 186 KB
Vyvanse (Binge Eating Disorder)
PDF, 190 KB
PDF, 190 KB
Vyvgart_Vyvgart Hytrulo (Medical)
PDF, 218 KB
PDF, 218 KB
Wakix
PDF, 215 KB
PDF, 215 KB
Weight Management Drugs (Group Specific Benefit)
(benzphetamine 50 mg | Contrave | diethylpropion IR/ER | Lomaira | phendimetrazine IR | phentermine HCL | Qsymia | Saxenda | Wegovy | Xenical | Zepbound)
PDF, 173 KB
(benzphetamine 50 mg | Contrave | diethylpropion IR/ER | Lomaira | phendimetrazine IR | phentermine HCL | Qsymia | Saxenda | Wegovy | Xenical | Zepbound)
PDF, 173 KB
Xacduro (Medical)
PDF, 222 KB
PDF, 222 KB
Xadago
PDF, 133 KB
PDF, 133 KB
Xdemvy
PDF, 156 KB
PDF, 156 KB
Xeljanz | Xeljanz XR
PDF, 218 KB
PDF, 218 KB
Xenleta (Medical)
PDF, 168 KB
PDF, 168 KB
Xenleta (Pharmacy)
PDF, 133 KB
PDF, 133 KB
Xenpozyme (Medical)
PDF, 237 KB
PDF, 237 KB
Xiaflex (Medical)
PDF, 205 KB
PDF, 205 KB
Xifaxan
PDF, 180 KB
PDF, 180 KB
Xofigo (Medical)
PDF, 213 KB
PDF, 213 KB
Xolair (Medical)
PDF, 463 KB
PDF, 463 KB
Xolair (Pharmacy)
PDF, 455 KB
PDF, 455 KB
Xphozah
PDF, 166 KB
PDF, 166 KB
Ycanth (Medical)
PDF, 165 KB
PDF, 165 KB
Yescarta (Medical)
PDF, 212 KB
PDF, 212 KB
Zeposia - Diagnosis: Ulcerative Colitis (UC))
PDF, 142 KB
PDF, 142 KB
Zevalin (Medical)
PDF, 231 KB
PDF, 231 KB
Zinplava (Medical)
PDF, 232 KB
PDF, 232 KB
Zokinvy
PDF, 191 KB
PDF, 191 KB
Zolgensma IV (Medical)
PDF, 218 KB
PDF, 218 KB
zolmitriptan (Zomig) Nasal Spray
PDF, 155 KB
PDF, 155 KB
Zontivity
PDF, 181 KB
PDF, 181 KB
Zorbtive
PDF, 186 KB
PDF, 186 KB
Ztalmy
PDF, 144 KB
PDF, 144 KB
Zulresso Injection (Medical)
(Behavioral Health Medical)
PDF, 173 KB
(Behavioral Health Medical)
PDF, 173 KB
Zurzuvae
PDF, 162 KB
PDF, 162 KB
Zyflo | Zileuton ER
PDF, 137 KB
PDF, 137 KB
Zynteglo (Medical)
PDF, 223 KB
PDF, 223 KB