Providers

Drug-Specific Pharmacy Prior Authorizations
Medicare Advantage

2025

Pharmacy Prior Authorization Requirements for Medicare

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

2025 Pharmacy Prior Authorization Forms:

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.

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.

Part D Step Therapy Authorization Forms

The following forms are downloadable in PDF format:

Febuxostat Step Therapy
Sancuso Step Therapy		 Spritam Step Therapy
Antipsychotics Brand Step Therapy

Part B Step Therapies

Part B drugs are subject to Step Therapy; our step therapy guidelines are reflected with the document below:

2025 Part B Step Therapy preferred drug list