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Drug Specific Prior Authorizations 2024 (Medicare)

View the complete list of CMS-approved Prior Authorization criteria by plan by clicking on one of the links below:

The following forms are downloadable in PDF format.

Acitretin

Actimmune

Acute Seizure Agents

Adempas

Adalimumab-aacf

Alpha1-Proteinase Inhibitors

Apomorphine Injection

Arcalyst injection

Austedo

Benlysta

Besremi

Bexarotene gel

Botulinum Toxins

Bronchitol

Carglumic Acid

Cayston

CFTR Modulators

CGRP Antagonists

Cinryze

Corticotropin injection gel

Cystaran

Deferiprone

Deferasirox

Diacomit

Dihydroergotamine nasal spray

Dronabinol

Dupixent

Enbrel

Endari

Endothelin Receptor Antagonists

Epidiolex

ESRD

Fasenra

Fentanyl Citrate Transmucosal lozenger

Filgrastim Agents

Fintepla

Gattex

Haegarda 

Harvoni

Hetlioz

High Risk-General

High Risk-Butalbital Combinations

High Risk-First Generation Antihistamines

High Risk-Non-Benzo Sedative Hypnotics

High Risk-Non-Cox Selective NSAIDs

High Risk-Skeletal Muscle Relaxants

Hospice

Humira

Icatibant

Ingrezza

Intravenous Immune Globulin (IVIG)

Kerendia

Kesimpta

Korlym

Libervant

Lidocaine Patches

Lucemyra

Mavyret

Myalept

Natpara

Nexletol, Nexlizet

Norditropin

Nucala

Nuedexta

Nuplazid

Ocaliva

Ofev

Oncology Agents: Oral

Otezla

Oxervate

Panretin

Part B vs D

PDE5 Inhibitor

Pegfilgrastim Agents

Pirfenidone

Posaconazole

Pregabalin ER

Promacta

Ravicti

Recorlev

Regranex

Repatha

Rezurock

Rinvoq

Rufinamide

Skyrizi

Sodium phenylbutyrate

Sofosbuvir/velpatasvir

Stelara

Sympazan

Taltz

Tasimelteon

Teriparatide

Testosterone Products - Injectable

Testosterone Products - Topical

Tetrabenazine

Topical Retinoids

Uptravi

Valchlor gel 

Ventavis

Voriconazole 

Wakefulness-Promoting Agents

Xeljanz

Xermelo

Xgeva

Xifaxan

Xolair

Xyrem

Xywav

Ztalmy

Zurzuvae

 

 

2024 Step Therapy

Part D Step Therapy Authorization Forms - The following forms are downloadable in PDF format. 

Part B Step Therapy