Prior Authorization

Prior Authorization is required on some medications before your drug will be covered. If your health plan's drug list guide indicates that you need a Prior Authorization for a specific drug, your physician must submit a prior authorization request form to the health plan for approval. If the request is not approved, please remember that you always have the option to purchase the medication at your own expense. You can search this page by using the search function within your application. (Press Ctrl+F on Windows or Command+F on Mac to bring up the search bar).

Providers click here to complete patient prior authorization. View instructions for completing the form.

Or you may submit electronically or view medication-specific Prior Authorization program summaries or forms by clicking on one of the following medication names below.

Health Care Service Corporation (HCSC) has utilization management programs that serve as guidelines for health care benefit coverage decisions, which may vary according to the different formularies and benefit plans offered by each state.

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Standard Utilization Management Programs

Accrufer
Accrufer
Accrufer Fax Form
Accrufer Program Summary

Actinic Keratosis
Diclofenac 3% Gel:
generic diclofenac 3% gel (For Voltaren/diclofenac 1% gel, please refer to Topical NSAID Step Therapy Program)

Fluorouracil Cream:
Carac, Efudex, Efudex Cream Kit, Fluorouracil cream, Fluoroplex, Tolak

Imiquimod Cream:
Aldara, Imiquimod, Zyclara

Tirbanibulin Ointment:
Klisyri
Actinic Keratosis Fax Form
Actinic Keratosis Program Summary

Acute Migraine
dihydroergotamine mesylate, Elyxyb, Migranal, Reyvow, Trudhesa
  Acute Migraine Fax Form
  Acute Migraine Program Summary

Afrezza
Afrezza
  Afrezza Fax Form
  Afrezza Program Summary

Agamree Emflaza
Agamree, Emflaza (deflazacort)
Agamree Emflaza Fax Form
Agamree Emflaza Program Summary

Alternative Dosage Form
Carafate (sucralfate) oral suspension, Cuvposa (glycopyrrolate) oral solution, Diphenoxylate/atropine, Epaned (enalapril) oral solution, Entresto (sacubitril-valsartan) caps, Fleqsuvy (baclofen) oral suspension, Gimoti (metoclopramide HCl) nasal spray, Indocin (indomethacin) suppositories, Indocin (indomethacin) suspension, Katerzia (amlodipine) oral suspension, Lyvispha (baclofen) granules, Meloxicam oral suspension, Naprosyn (naproxen) oral suspension, Nexium (esomeprazole) delayed-release oral suspension, Norliqva (amlodipine) oral solution, Ozobax (baclofen) oral solution, Qbrelis (lisinopril) oral solution, Sotylize (sotalol) oral solution, Sprix (ketorolac) nasal spray/ Ketorolac nasal spray, Tiglutik (riluzole) oral suspension
Alternative Dosage Form Fax Form
Alternative Dosage Form Program Summary

Amifampridine
Firdapse
Amifampridine Fax Form
Amifampridine Program Summary

Androgens Anabolic Steroids
Androderm, AndroGel, Aveed, Azmiro, danazol, Depo-Testosterone, Fortesta, Jatenzo, Kyzatrex, Methitest, methyltestosterone capsule, Natesto, Testim, Testopel, testosterone gel/solution, TLANDO, Undecatrex,Vogelxo, Xyosted
Androgens Anabolic Steroids Fax Form
Androgens Anabolic Steroids Program Summary

Antifungals
Brexafemme, Cresemba, Noxafil, posaconazole, Tolsura, Vfend, Vivjoa, voriconazole
Antifungals Fax Form
Antifungals Program Summary

Arikayce
Arikayce
  Arikayce Fax Form
  Arikayce Program Summary

ATTR Amyloidosis
Tegsedi, Vyndamax, Vyndaqel, Wainua
  ATTR Amyloidosis Fax Form
  ATTR Amyloidosis Program Summary

Bempedoic Acid
Nexletol, Nexlizet
Bempedoic Acid Fax Form
Bempedoic Acid Program Summary

Biologic Immunomodulators
Abrilada, Actemra, Amjevita, Bimzelx, Cimzia, Cosentyx, Cyltezo, Enbrel, Entyvio, Hadlima, Hulio, Humira, Hyrimoz, Idacio, Kevzara, Kineret, Litfulo, Olumiant, Omvoh, Orencia, Otulfi, Pyzchiva, Rinvoq, Selarsdi, Siliq, Simlandi, Simponi, Skyrizi, Sotyktu, Stelara, Steqeyma, Taltz, Tremfya, Tyenne, Velsipity, Wezlana, Xeljanz, Xeljanz XR, Yesintek, Yuflyma, Yusimry, Zymfentra
Biologic Immunomodulators Fax Form
Biologic Immunomodulators Program Summary

Biologic Immunomodulators (for Balanced Biosimilar, Performance Select Biosimilar, and Performance Biosimilar)
Abrilada, Actemra, Amjevita, Bimzelx, Cimzia, Cosentyx, Cyltezo, Enbrel, Entyvio, Hadlima, Hulio, Humira, Hyrimoz, Idacio, Kevzara, Kineret, Litfulo, Olumiant, Omvoh, Orencia, Otulfi, Pyzchiva, Rinvoq, Selarsdi, Siliq, Simlandi, Simponi, Skyrizi, Sotyktu, Stelara, Steqeyma, Taltz, Tremfya, Tyenne, Velsipity, Wezlana, Xeljanz, Xeljanz XR, Yesintek, Yuflyma, Yusimry, Zymfentra
Biologic Immunomodulators (for Balanced Biosimilar, Performance Select Biosimilar, and Performance Biosimilar) Fax Form
Biologic Immunomodulators (for Balanced Biosimilar, Performance Select Biosimilar, and Performance Biosimilar) Program Summary

Bonjesta Diclegis
Bonjesta, Diclegis, doxylamine/pyridoxine delayed release
Bonjesta Diclegis Fax Form
Bonjesta Diclegis Program Summary

Calcitonin Gene-related Peptides (CGRP)
Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Ubrelvy, Zavzpret
Calcitonin Gene-related Peptides (CGRP) Fax Form
Calcitonin Gene-related Peptides (CGRP) Program Summary

Camzyos
Camzyos
  Camzyos Fax Form
  Camzyos Program Summary

Cannabidiol
Epidiolex
  Cannabidiol Fax Form
  Cannabidiol Program Summary

Cholestasis Pruritus
Bylvay, Livmarli
Cholestasis Pruritus Fax Form
Cholestasis Pruritus Program Summary

Cibinqo
Cibinqo
  Cibinqo Fax Form
  Cibinqo Program Summary

Coagulation Factor VIIa
NovoSeven RT, Sevenfact
  Coagulation Factor VIIa Fax Form
  Coagulation Factor VIIa Program Summary

Combination NSAIDs
aspirin/omeprazole, Consensi, Duexis, Vimovo, Yosprala
  Combination NSAIDs Fax Form
  Combination NSAIDs Program Summary

Constipation Agents
Amitiza (lubiprostone), Ibsrela, Motegrity (prucalopride succinate), Relistor
Constipation Agents Fax Form
Constipation Agents Program Summary

Continuous Glucose Monitor
Dexcom G6 CGM System, Dexcom G7 CGM System, Freestyle Libre, Freestyle Libre 2, Freestyle Libre 3
Continuous Glucose Monitor Fax Form
Continuous Glucose Monitor Program Summary

Corticotropin
Acthar, Acthar gel, Cortrophin, Purified Cortrophin Gel
Corticotropin Fax Form
Corticotropin Program Summary

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
Alyftrek, Kalydeco, Orkambi, Symdeko, Trikafta
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Fax Form
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Program Summary

Daybue
Daybue
Daybue Fax Form
Daybue Program Summary

Dry Eye Disease
Cequa, cyclosporine ophthalmic emulsion, Eysuvis, Miebo, Restasis, Tyrvaya, Vevye, Xiidra
Dry Eye Disease Fax Form
Dry Eye Disease Program Summary

Dojolvi
Dojolvi
Dojolvi Fax Form
Dojolvi Program Summary

Duvyzat
Duvyzat
Duvyzat Fax Form
Duvyzat Program Summary

Egrifta
Egrifta SV
Egrifta Fax Form
Egrifta Program Summary

Elagolix Relugolix
Myfembree, Oriahnn, Orilissa
Elagolix Relugolix Fax Form
Elagolix Relugolix Program Summary

Eohilia
Eohilia
Eohilia Fax Form
Eohilia Program Summary

Empaveli
Empaveli
  Empaveli Fax Form
  Empaveli Program Summary

Endari
Endari (L-glutamine)
  Endari Fax Form
  Endari Program Summary

Enspryng
Enspryng
Enspryng Fax Form
Enspryng Program Summary

Erythropoietins
Aranesp, Epogen, Mircera, Procrit, Retacrit
Erythropoietins Fax Form
Erythropoietins Program Summary

Fabhalta
Fabhalta
Fabhalta Fax Form
Fabhalta Program Summary

Factor VIII and von Willebrand Factor
Advate, Adynovate, Afstyla, Alphanate, Altuviiio, Eloctate, Esperoct, Helixate FS, Hemofil M, Humate-P, Jivi, Koāte, Koāte-DVI, Kogenate FS, Kovaltry, Monoclate-P, NovoEight, Nuwiq, Recombinate, Vonvendi, Wilate, Xyntha, Xyntha Solofuse
Factor VIII and von Willebrand Factor Fax Form
Factor VIII and von Willebrand Factor Program Summary

Filspari
Filspari
Filspari Fax Form
Filspari Program Summary

Filsuvez
Filsuvez
Filsuvez Fax Form
Filsuvez Program Summary

Fintepla
Fintepla
Fintepla Fax Form
Fintepla Program Summary

Furoscix
Furoscix
Furoscix Fax Form
Furoscix Program Summary

Galafold
Galafold
Galafold Fax Form
Galafold Program Summary

Gattex
Gattex
Gattex Fax Form
Gattex Program Summary

General PA/ST Fax Form
This fax form should only be used when a drug specific one is not found. Using the general PA/ST fax form when a drug specific form is available may result in delays with processing your request.
General PA/ST Fax Form

Glucagon-like Peptide-1 (GLP-1)
Adlyxin, Bydureon Bcise, Byetta, Liraglutide, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza/liraglutide
Glucagon-like Peptide-1 (GLP-1) Fax Form
Glucagon-like Peptide-1 (GLP-1) Program Summary

Growth Hormones
Genotropin, Genotropin Miniquick, Humatrope, Humatropen, Ngenla, Norditropin Flexpro, Nutropin AQ Nuspin, Omnitrope, Saizen, saizenprep, Serostim, Skytrofa, Sogroya, Zomacton, Zorbtive
Growth Hormones Fax Form
Growth Hormones Program Summary

HCN Channel Blocker
Corlanor (ivabradine)
HCN Channel Blocker Fax Form
HCN Channel Blocker Program Summary

Health Care Provider Administered (HCPA) Biologic Immunomodulators
Actemra, Avsola, Cimzia, Consentyx, Entyvio, Ilumya, Inflectra, Omvoh, Orencia, Otulfi, Pyzchiva, Remicade, Renflexis, Selarsdi, Simponi ARIA, Skyrizi, Stelara, Steqeyma, Tofidence, Tremfya, Tyenne, Wezlana, Yesintek
  Health Care Provider Administered (HCPA) Biologic Immunomodulators Fax Form
  Health Care Provider Administered (HCPA) Biologic Immunomodulators Program Summary

Hemlibra
Hemlibra
  Hemlibra Fax Form
  Hemlibra Program Summary

Hemophilia Factor IX
AlphaNine SD, Alprolix, BeneFIX, Idelvion, Ixinity, Profilnine SD, Rebinyn, Rixubis
Hemophilia Factor IX Fax Form
Hemophilia Factor IX Program Summary

Hepatitis C Direct Acting Antivirals
Epclusa, Harvoni, Ledipasvir/Sofosbuvir, Mavyret, Sofosbuvir/Velpatasvir, Sovaldi, Viekira PAK, Vosevi, Zepatier
  Hepatitis C Direct Acting Antivirals Fax Form
  Hepatitis C Direct Acting Antivirals Program Summary

Hereditary Angioedema
Berinert, Cinryze, Firazyr, Haegarda, icatibant, Orladeyo, Ruconest, Takhzyro
  Hereditary Angioedema Fax Form
  Hereditary Angioedema Program Summary

Hetlioz
Hetlioz, Hetlioz LQ, Tasimelteon
Hetlioz Fax Form
Hetlioz Program Summary

Hyftor
Hyftor
Hyftor Fax Form
Hyftor Program Summary

Hyperhidrosis
Qbrexza, Sofdra
Hyperhidrosis Fax Form
Hyperhidrosis Program Summary

Hypoactive Sexual Desire Disorder (HSDD)
Addyi, Vyleesi
Hypoactive Sexual Desire Disorder (HSDD) Fax Form
HHypoactive Sexual Desire Disorder (HSDD) Program Summary

Hympavzi
Hympavzi
Hympavzi Fax Form
Hympavzi Program Summary

IL-1 Inhibitors
Arcalyst
IL-1 Inhibitors Fax Form
IL-1 Inhibitors Program Summary

IL-13 Antagonist
Adbry, Ebglyss
IL-13 Antagonist Fax Form
IL-13 Antagonist Program Summary

IL-4 Inhibitors
Dupixent
  IL-4 Inhibitors Fax Form
  IL-4 Inhibitors Program Summary

IL-5 Inhibitor
Fasenra, Nucala
  IL-5 Inhibitor Fax Form
  IL-5 Inhibitor Program Summary

IL-31 Inhibitors
Nemluvio
IL-31 Inhibitors Fax Form
IL-31 Inhibitors Program Summary

Imcivree
Imcivree
Imcivree Fax Form
Imcivree Program Summary

Insulin Pump
Ilet insulin pump, Omnipod DASH/Omnipod 5, Omnipod DASH kit/Omnipod 5 kit, Twiist
Insulin Pump Fax Form
Insulin Pump Program Summary

Interstitial Lung Disease
Esbriet, Ofev, Pirfenidone
Interstitial Lung Disease Fax Form
Interstitial Lung Disease Program Summary

Irritable Bowel Syndrome (IBS-D)
Lotronex, Viberzi, Xifaxan
Irritable Bowel Syndrome (IBS-D) Fax Form
Irritable Bowel Syndrome (IBS-D) Program Summary

Iron Chelation
Deferasirox, Exjade, Ferriprox, Jadenu
  Iron Chelation Fax Form
  Iron Chelation Program Summary

Isturisa
Isturisa
  Isturisa Fax Form
  Isturisa Program Summary

Joenja
Joenja
Joenja Fax Form
Joenja Program Summary

Jynarque
Jynarque
  Jynarque Fax Form
  Jynarque Program Summary

Kerendia
Kerendia
  Kerendia Fax Form
  Kerendia Program Summary

Korlym
Korlym (mifepristone)
Korlym Fax Form
Korlym Program Summary

Luminopia
Luminopia
Luminopia Fax Form
Luminopia Program Summary

Lupus
Benlysta, Lupkynis
Lupus Fax Form
Lupus Program Summary

Metformin
Glumetza (metformin modified release), Metformin 625mg and 750mg, Metformin ER osmotic release, Riomet
Metformin Fax Form
Metformin Program Summary

Multiple Sclerosis
Aubagio, Avonex, Bafiertam, Betaseron, Copaxone, dimethyl fumarate, Extavia, fingolimod, Gilenya, glatiramer, Glatopa, Kesimpta, Mavenclad, Mayzent, Plegridy, Ponvory, Rebif, Tascenso ODT, Tecfidera, Vumerity
Multiple Sclerosis Fax Form
Multiple Sclerosis Program Summary

Myalept
Myalept
Myalept Fax Form
Myalept Program Summary

Neurotrophic Keratitis
Oxervate
Neurotrophic Keratitis Fax Form
Neurotrophic Keratitis Program Summary

Niemann-Pick Disease Type C Agents
Aqneursa, Miplyffa
Niemann-Pick Disease Type C Agents Fax Form
Niemann-Pick Disease Type C Agents Program Summary

Non-Preferred Brand Alternatives
Alocril, Altabax, Cortisporin-tc, Crotan, Dipentum, Emverm, Lastacaft, Mirvaso, Neupro, Otovel, Pradaxa, Rectiv, Ryclora, Santyl, Zerviate
  Non-Preferred Brand Alternatives Fax Form
  Non-Preferred Brand Alternatives Program Summary

Northera
Northera, droxidopa
  Northera Fax Form
  Northera Program Summary

Ohtuvayre
Ohtuvayre
Ohtuvayre Fax Form
Ohtuvayre Program Summary

Onychomycosis
ciclopirox, itraconazole, Jublia, Kerydin, Sporanox, tavaborole
Onychomycosis Fax Form
Onychomycosis Program Summary

Opioids
Oxycontin
Opioids Fax Form
Opioids Program Summary

Opzelura
Opzelura
Opzelura Fax Form
Opzelura Program Summary

Oral Tetracycline Derivatives
Acticlate, Doryx, Doryx MPC, doxycycline, Doxycycline monohydrate, Emrosi, Minocin, minocycline tablet, Minocycline ER, Minolira, Oracea, Seysara, Solodyn, Targadox, tetracycline, Vibramycin, Ximino
Oral Tetracycline Derivatives Fax Form
Oral Tetracycline Derivatives Program Summary

Otezla
Otezla
Otezla Fax Form
Otezla Program Summary

Oxybate
Lumryz, Xyrem, Xywav
Oxybate Fax Form
Oxybate Program Summary

Pancreatic Enzymes
Creon, Pancreaze, Pertzye, Viokace, Zenpep
Pancreatic Enzymes Fax Form
Pancreatic Enzymes Program Summary

Parathyroid Hormone Analog Osteoporosis
Forteo, Teriparatide, Tymlos
Parathyroid Hormone Analog Osteoporosis Fax Form
Parathyroid Hormone Analog Osteoporosis Program Summary

Peginterferon
Pegasys
  Peginterferon Fax Form
  Peginterferon Program Summary

Phenylketonuria
Kuvan, Palynziq, sapropterin
  Phenylketonuria Fax Form
  Phenylketonuria Program Summary

Primary Biliary Cholangitis
Iqirvo, Ocaliva, Livdelzi
Primary Biliary Cholangitis Fax Form
Primary Biliary Cholangitis Program Summary

Procysbi
Procsybi
  Procysbi Fax Form
  Procysbi Program Summary

PCSK9 Inhibitors
Praluent, Repatha
  PCSK9 Inhibitors Fax Form
  PCSK9 Inhibitors Program Summary

Pseudobulbar Affect
Nuedexta
Pseudobulbar Affect Fax Form
Pseudobulbar Affect Program Summary

Pulmonary Arterial Hypertension (PAH)
Adcirca, Adempas, Alyq, ambrisentan, bosentan, Letairis, Liqrev, Opsumit, Opsynvi, Orenitram, Revatio, sildenafil, tadalafil, Tadliq, Tracleer, Tyvaso, Uptravi, Ventavis, Winrevair
Pulmonary Arterial Hypertension (PAH) Fax Form
Pulmonary Arterial Hypertension (PAH) Program Summary

Pyrukynd
Pyrukynd
Pyrukynd Fax Form
Pyrukynd Program Summary

Radicava
Radicava
Radicava Fax Form
Radicava Program Summary

Rapid to Intermediate Acting Insulin
Admelog, Apidra, Humalog, Humalog Junior Kwikpen, Humalog Kwikpen U200, Humalog Mix 50/50, Humalog Mix 75/25, Humalog Tempo, Humulin 70/30, Humulin N, Humulin R U-100, Insulin Aspart, Insulin Lispro, Insulin Lispro Junior Kwikpen, Insulin Lispro Kwikpen, Insulin Lispro Protamine/Insulin Lispro Kwikpen (75/25), Lyumjev, Lyumjev Tempo
Rapid to Intermediate Acting Insulin Fax Form
Rapid to Intermediate Acting Insulin Program Summary

Rayos
Rayos
Rayos Fax Form
Rayos Program Summary

Recorlev
Recorlev
Recorlev Fax Form
Recorlev Program Summary

Resmetirom
Rezdiffra
Resmetirom Fax Form
Resmetirom Program Summary

Retinoids
Adapalene, Aklief, Altreno/tretinoin, Arazlo, Atralin/tretinoin, Avita/tretinoin, Differin/adapalene, Epiduo Forte/Adapalene-Benzoyl Peroxide, Epiduo/Adapalene-Benzoyl Peroxide, Fabior, Retin-A/tretinoin, Retin-A micro/tretinoin, Tazorac/tazarotene, Twyneo, Veltin/Clindamycin Phosphate-Tretinoin, Ziana/Clindamycin Phosphate-Tretinoin
Retinoids Fax Form
Retinoids Program Summary

Rezurock
Rezurock
Rezurock Fax Form
Rezurock Program Summary

Risdiplam
Evrysdi
Risdiplam Fax Form
Risdiplam Program Summary

Rivfloza
Rivfloza
Rivfloza Fax Form
Rivfloza Program Summary

Selective Serotonin Inverse Agonist (SSIA)
Nuplazid
Selective Serotonin Inverse Agonist (SSIA) Fax Form
Selective Serotonin Inverse Agonist (SSIA) Program Summary

SA Oncology
Afinitor/everolimus, Afinitor Disperz/everolimus, Akeega, Alecensa, Alunbrig, Augtyro, Ayvakit, Balversa, BESREMi, Bosulif, Braftovi, Brukinsa, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Danziten, Daurismo, Erivedge, Erleada, Exkivity, Fotivda, Fruzaqla, Gavreto, Gilotrif, Gleevec/imatinib, Gomekli, Hycamtin, Ibrance, Iclusig, Idhifa, Imbruvica, Imkeldi, Inlyta, Inqovi, Inrebic, Iressa/gefitinib, Itovebi, Iwilfin, Jakafi, Jaypirca, Kisqali, Kisqali Femara Pack, Koselugo, Krazati, Lazcluze, Lenvima, Lonsurf, Lorbrena, Lumakras, Lynparza, Lysodren, Lytgobi, Matulane, Mekinist, Mektovi, Nerlynx, Nexavar/sorafenib, Ninlaro, Nubeqa, Odomzo, Ogsiveo, Ojemda, Ojjaara, Onureg, Orgovyx, Orserdu, Pemazyre, Piqray, Pomalyst, Qinlock, Retevmo, Revlimid/lenalidomide, Revuforj, Rezlidhia, Romvimza, Rozlytrek, Rubraca, Rydapt, Scemblix, Sprycel/dasatinib, Stivarga, Sutent/sunitinib, Tabrecta, Tafinlar, Tagrisso, Talzenna, Tarceva/erlotinib, Targretin/bexarotene, Tasigna, Tazverik, Temodar, Temozolomide, Tepmetko, Thalomid, Tibsovo, Tretinoin, Truqap, Truseltiq, Tukysa, Turalio, Tykerb/lapatinib, Vanflyta, Venclexta, Verzenio, Vitrakvi, Vizimpro, Vonjo, Voranigo, Votrient/pazopanib, Welireg, Xalkori, Xeloda/capecitabine, Xospata, Xpovio, Xtandi, Yonsa, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga/abiraterone
SA Oncology Fax Form
SA Oncology Program Summary

Skyclarys
Skyclarys
Skyclarys Fax Form
Skyclarys Program Summary

Somatostatins
Mycapssa, Somavert
Somatostatins Fax Form
Somatostatins Program Summary

Sohonos
Sohonos
Sohonos Fax Form
Sohonos Program Summary

Spevigo
Spevigo
Spevigo Fax Form
Spevigo Program Summary

Strensiq
Strensiq
Strensiq Fax Form
Strensiq Program Summary

Substrate Reduction Therapy
Cerdelga, miglustat, Opfolda, Zavesca
Substrate Reduction Therapy Fax Form
Substrate Reduction Therapy Program Summary

Sucraid
Sucraid
Sucraid Fax Form
Sucraid Program Summary

Sunosi
Sunosi
  Sunosi Fax Form
  Sunosi Program Summary

Supplemental Therapeutic Alternatives
Crexont, Daraprim, Elepsia XR, Rytary
  Supplemental Therapeutic Alternatives Fax Form
  Supplemental Therapeutic Alternatives Program Summary

Tarpeyo
Tarpeyo
Tarpeyo Fax Form
Tarpeyo Program Summary

Tavneos
Tavneos
Tavneos Fax Form
Tavneos Program Summary

Tezspire
Tezspire
Tezspire Fax Form
Tezspire Program Summary

Therapeutic Alternatives
Absorica/Absorica LD, Adapalene, AirDuo Respiclick, Ala-Scalp, Alphagan-P, Amrix, Aplenzin, Ativan, Azelex, Bethkis, Bupap, Cabtreo, Cafergot, Cambia/diclofenac, Carbinoxamine Maleate 6mg, Chlorzoxazone/Parafon Forte, Cordran, Coxanto, Cuprimine, Denavir Cream 1%, Diflorasone/Psorcon cream, diflorasone ointment, diclofenac potassium, Doral, Econazole Nitrate 1% foam, Epinephrine, Ergomar, Ertaczo 2% cream, Exelderm 1% cream, Exelderm 1% solution, Extina, Fenoprofen, fenofibrate 120 mg, Fexmid/cyclobenzaprine, Flurazepam, Halog, Innopran XL, Kenalog spray, Ketoprofen ER 200mg, Ketoprofen 25 mg, Ketoprofen 50 mg, Konvomep suspension, Lexette, Librax, Lorzone, Luzu 1% cream, mefenamic acid, mupirocin cream, naftifine 1% cream, Naftin 2% cream, Naftin 1% gel, Naftin 2% gel, Nalfon, Nalocet, Naprelan, Neffy, Noritate, Oxistat, phospholine ophthalmic solution, prednisolone sodium phosphate solution, prednisolone tablet, Prolate, Reltone, Rhofade, Sitavig, Sorilux, Sovuna, Tanlor, TOBI/Kitabis, TOBI Podhaler, Treximet 85/500mg, Vivlodex, Wellbutrin XL, Xerese, Zegerid/omeprazole-sodium bicarbonate, Zembrace, Zipsor, Zovirax cream 5%, Zyflo, Zyflo CR/zileuton CR
Therapeutic Alternatives Fax Form
Therapeutic Alternatives Program Summary

Thrombopoietin Receptor Agonists and Tavalissee
Alvaiz, Doptelet, Mulpleta, Nplate, Promacta, Tavalisse
Thrombopoietin Receptor Agonists Fax Form
Thrombopoietin Receptor Agonists Program Summary

Topical Doxepin
Doxepin 5% cream, Prudoxin, Zonalon
Topical Doxepin Fax Form
Topical Doxepin Program Summary

Topical Lidocaine
Lidoderm/lidocaine, lidocaine ointment, Pliaglis, Synera, ZTlido
Topical Lidocaine Fax Form
Topical Lidocaine Program Summary

Topiramate Extended Release
Qudexy XR, topiramate ER, Trokendi XR
Topiramate Extended Release Fax Form
Topiramate Extended Release Program Summary

Tryvio
Tryvio
Tryvio Fax Form
Tryvio Program Summary

Urea Cycle Disorders
Buphenyl, Olpruva, Pheburane, Ravicti, sodium phenylbutyrate
Urea Cycle Disorders Fax Form
Urea Cycle Disorders Program Summary

Vascepa
icosapent ethyl, Vascepa
Vascepa Fax Form
Vascepa Program Summary

Vasomotor Symptoms
Veozah
Vasomotor Symptoms Fax Form
Vasomotor Symptoms Program Summary

Verkazia
Verkazia
Verkazia Fax Form
Verkazia Program Summary

Verquvo
Verquvo
Verquvo Fax Form
Verquvo Program Summary

Vijoice
Vijoice
Vijoice Fax Form
Vijoice Program Summary

Vitamin B12 Deficiency
Nascobal
Vitamin B12 Deficiency Fax Form
Vitamin B12 Deficiency Program Summary

VMAT2 Inhibitors
Austedo, Austedo XR, Ingrezza, tetrabenazine, Xenazine
VMAT2 Inhibitors Fax Form
VMAT2 Inhibitors Program Summary

Vowst
Vowst
Vowst Fax Form
Vowst Program Summary

Voxzogo
Voxzogo
Voxzogo Fax Form
Voxzogo Program Summary

Voydeya
Voydeya
Voydeya Fax Form
Voydeya Symptoms Program Summary

Vtama
Vtama
Vtama Fax Form
Vtama Program Summary

Wakix
Wakix
Wakix Fax Form
Wakix Program Summary

Weight Loss
Adipex-P, Benzphetamine, Contrave, Diethylpropion, Lomaira, Phendimetrazine, Qsymia, Xenical
Weight Loss Fax Form
Weight Loss Program Summary

Weight Management
Saxenda, Wegovy, Zepbound
Weight Management Fax Form
Weight Management Program Summary

Winlevi
Winlevi
Winlevi Fax Form
Winlevi Program Summary

Xhance
Xhance
  Xhance Fax Form
  Xhance Program Summary

Xolair
Xolair
  Xolair Fax Form
  Xolair Program Summary

Xolremdi
Xolremdi
Xolremdi Fax Form
Xolremdi Program Summary

Xphozah
Xphozah
Xphozah Fax Form
Xphozah Program Summary

Yorvipath
Yorvipath
Yorvipath Fax Form
Yorvipath Program Summary

Zeposia
Zeposia
Zeposia Fax Form
Zeposia Program Summary

Zilbrysq
Zilbrysq
Zilbrysq Fax Form
Zilbrysq Program Summary

Zokinvy
Zokinvy
Zokinvy Fax Form
Zokinvy Program Summary

Zoryve
Zoryve
Zoryve Fax Form
Zoryve Program Summary

Non-Standard Utilization Management Programs for Select Groups

Illinois Uniform Prior Authorization
Illinois Uniform Prior Authorization Fax Form