Drug Prior Authorization Forms

Contact Pharmacy Services at (608) 260-7803, (800) 545-5015, or pharmacyinfo@pplusic.com 

For Health Insurance Marketplace members with an urgent life-threatening medication prior authorization request please contact (608) 260-7803 or fax (608) 327-0324 Monday through Friday before 5 p.m. and contact (608) 381-4723 or fax (608) 327-0324 after 5 p.m. on Friday through 5 p.m. on Sunday. See the Health Insurance Marketplace Formulary Expedited Prior Authorization Procedure/Exception Procedure in the Health Insurance Marketplace Formulary.


Standard Prior Authorization Request: Medication PA Request Form 

Step Therapy Criteria
Legacy Formulary
Hybrid Formulary
Health Insurance Marketplace Forumlary


Forms listed alphabetically by their brand name

A
Actemra (tocilizumab) – Medical Benefit Drug
Acthar Gel (repository corticotropin)
Adempas (riociguat)
Amitiza (lubiprostone)
Ampyra (dalfampridine)
Androgel (testosterone gel)
Androderm (testosterone transdermal)
Apokyn (apomorphine)
Arcalyst (rilonacept) – Medical Benefit Drug
Aubagio (teriflunomide)
Avita (tretinoin 0.025%)
Azelex (azelaic acid 20%)

B
Banzel (rufinamide)
Benlysta (belimumab) – Medical Benefit Drug
Berinert (C1 Esterase Inhibitor) - Medical Benefit Drug
Betaseron (interferon beta-1b)
Boniva (ibandronate intravenous) - Medical Benefit Drug

C
Carimune NF (immune globulin) - Medical Benefit Drug
Cayston (aztreonam lysine Inhalation Solution)
Cerezyme (imiglucerase) - Medical Benefit Drug
Cimzia (certolizumab)
Cinryze (C1 Esterase Inhibitor) - Medical Benefit Drug
Compounds (>$100)

D
Differin (adapalene)
Dificid (fidaxomicin)
Dutoprol (metoprolol succinate / HCTZ)


Elelyso (taliglucerase alfa) - Medical Benefit Drug
Emsam Patch (selegilene)
Entocort EC (budesonide) 
Entyvio (vedolizumab) - Medical Benefit Drug
Erivedge (vismodegib)
Extavia (interferon beta-1b)

F
Fanapt (iloperidone)
Finacea (azelaic acid 15%)
Firazyr (icatibant)
Flebogamma (immune globulin) - Medical Benefit Drug
Forteo (teriparatide)

G
Gammagard Liquid (immune globulin) - Medical Benefit Drug
Gammagard S/D (immune globulin) - Medical Benefit Drug
Gammaplex (immune globulin) - Medical Benefit Drug
Gammar-P I.V. (immune globulin) - Medical Benefit Drug
Gamunex (immune globulin) - Medical Benefit Drug
Gilenya (fingolimod)
Glucose Test Strip Quantity Limit
Grastek (grass pollen allergen)
Growth Hormone - Initiation
Growth Hormone - Continuation

H
Harvoni (sofosbuvir/ledipasvir)
Hereditary Angioedema
Hizentra (immune globulin) - Medical Benefit Drug
Humira (adalimumab)

I
Ilaris (canakinumab) – Medical Benefit Drug
Immunoglobulin (IV & SC) - Medical Benefit Drug
Intuniv (guanfacine)
Invega (paliperidone)

K
Kalbitor (ecallantide) — Medical Benefit Drug

L
Latuda (lurasidone)
Letairis (ambrisentan)
Lidoderm Patch (lidocaine patch 5%)
Linzess (linaclotide)
Lovaza (omega-3-acids)
Lyrica (pregabalin)

M
Mekinist (trametinib)
Metozolv ODT (metoclopramide)
Multiple Sclerosis (interferons)

N
Noxafil (posaconazole)
Nplate (romiplostim)

O
Olysio (simeprevir)
Onfi (clobazam) 
Oral and Infused Cancer Medications
Orencia (abatacept) - Medical Benefit Drug
Opsumit (macitentatn)
Oxandrin (oxandrolone)

P
Patanol (olopatadine ophthalmic)
Potiga (ezogabine)
Privigen (immune globulin) - Medical Benefit Drug
Prolia (denosumab) – Medical Benefit Drug
Promacta (eltrombopag)

R
Ragwitek (short ragweed pollen allergen extract)
Rebif (interferon beta-1a)
Reclast (zoledronic acid intravenous) - Medical Benefit Drug
Regranex (becaplermin)
Relistor (methylnaltrexone)
Remicade (infliximab) - Medical Benefit Drug
Renova (tretinoin 0.02%)
Restasis (cyclosporine ophthalmic)
Retin-A-Micro (tretinoin)
Rituxan (rituximab) - Medical Benefit Drug

S
Sabril (vigabatrin)
Samsca (tolvaptan)
Savella (milnacipran) 
Soliris (Eculizumab)
Sovaldi (sofosbuvir)
Sporanox (itraconazole) 
Synagis (palivizumab) - Medical Benefit Drug

T
Taclonex (betamethasone dipropionate 0.064% calcipotriene 0.005%)
Tafinlar (dabrafenib) 
Tecfidera (dimethyl fumarate)
Testim (testosterone gel)
Testosterone Replacement
Tikosyn (dofetilide)
TNF Inhibitor
Toprol XL (metoprolol succinate)
Tracleer (bosentan)
Tretinoin & Vitamin A Analogues (topical)
Tysabri (natalizumab) - Medical Benefit Drug

Vfend (voriconazole)
Victrelis (boceprevir)
Viekira Pak (ombitasvir/paritaprevir/ritonavir/dasabuvir)
Vimpat (lacosamide) 
Vivaglobin (immune globulin) - Medical Benefit Drug
Vivitrol (naltrexone IM) - Medical and Pharmacy Benefit Drug

X
Xeljanz (tofacitinib)
Xenazine (tetrabenazine)
Xolair (omalizumab) - Medical Benefit Drug
Xylocaine (Lidocaine) Infusion for chronic pain

Y
Yervoy (ipilimumab) - Medical Benefit Drug

Z
Zavesca (miglustat)
Zelboraf (vemurafenib)
Zenpep (pancrelipase)


Forms listed alphabetically by their generic name

A
abatacept (Orencia) - Medical Benefit Drug
adalimumab (Humira)
adapalene (Differin)
ambrisentan (Letairis)
apomorphine (Apokyn)
azelaic acid 15% (Finacea)
azelaic acid 20% (Azelex)
aztreonam lysine Inhalation Solution (Cayston)

B
becaplermin (Regranex)
belimumab (Benlysta) – Medical Benefit Drug
betamethasone dipropionate 0.064% calcipotriene 0.005% (Taclonex)
boceprevir (Victrelis)
bosentan (Tracleer)
budesonide (Entocort EC)

C
C1 Esterase Inhibitor (Berinert) - Medical Benefit Drug
C1 Esterase Inhibitor (Cinryze) - Medical Benefit Drug
canakinumab (Ilaris) – Medical Benefit Drug
certolizumab (Cimzia)
clobazam (Onfi)
cyclosporine ophthalmic (Restasis) 
Compounds (>$100)

D
dabrafenib (Tafinlar)
dalfampridine (Ampyra)
denosumab (Prolia) – Medical Benefit Drug
dimethyl fumarate (Tecfidera)
dofetilide (Tikosyn)

E
ecallantide (Kalbitor) - Medical Benefit Drug 
Eculizumab (Soliris)
eltrombopag (Promacta) 
ezogabine (Potiga)

F
fidaxomicin (Dificid)
fingolimod (Gilenya)

G
Glucose Test Strip Quantity Limit
grass pollen allergen (Grastek)
Growth Hormone - Initiation
Growth Hormone - Continuation
guanfacine (Intuniv)

I
ibandronate intravenous (Boniva) - Medical Benefit Drug
icatibant (Firazyr)
iloperidone (Fanapt) 
Imiglucerase (Cerezyme) - Medical Benefit Drug
Immunoglobulin (IV & SC) - Medical Benefit Drug
infliximab (Remicade) - Medical Benefit Drug
interferon beta-1a (Rebif)
interferon beta-1b (Betaseron)
interferon beta-1b (Extavia)
Ipilimumab (Yervoy) - Medical Benefit Drug
itraconazole (Sporanox)

L
lacosamide (Vimpat) 
lidocaine infusion for chronic pain
lidocaine patch 5% (Lidoderm Patch)
linaclotide (Linzess)
lubiprostone (Amitiza)
lurasidone (Latuda)

M
macitentatn (Opsumit)
methylnaltrexone (Relistor)
metoclopramide (Metozolv ODT)
metoprolol succinate (Toprol XL)
metoprolol succinate / HCTZ (Dutoprol)
miglustat (Zavesca)
milnacipran (Savella)
Multiple Sclerosis (Interferons)

N
Naltrexone IM (Vivitrol) - Medical  and Pharmacy Benefit Drug
natalizumab (Tysabri) - Medical Benefit Drug 

O
olopatadine ophthalmic (Patanol) 
ombitasvir/paritaprevir/ritonavir/dasabuvir (Viekira Pak)
omalizumab (Xolair) - Medical Benefit Drug
omega-3-acids (Lovaza)
Oral and Infused Cancer Medications
oxandrolone (Oxandrin)

P
paliperidone (Invega)
palivizumab (Synagis) - Medical Benefit Drug
pancrelipase (Zenpep) 
posaconazole (Noxafil)
pregabalin (Lyrica)

R
ragweed pollen allergen extract (Ragwitek)
repository corticotropin (Acthar Gel)
rilonacept (Arcalyst) – Medical Benefit Drug
riociguat (Adempas)
rituximab (Rituxan) - Medical Benefit Drug
romiplostim (Nplate)
rufinamide (Banzel)


selegilene (Emsam Patch)
simeprevir (Olysio)
Sofosbuvir/ledipasvir (Harvoni)
sofosbuvir (Sovaldi) 

Taliglucerase alfa (Elelyso) - Medical Benefit Drug
teriflunomide (Aubagio)
teriparatide (Forteo)
Testosterone Replacement
tetrabenazine (Xenazine)
TNF Inhibitor
tocilizumab (Actemra) – Medical Benefit Drug
tofacitinib (Xeljanz)
tolvaptan (Samsca)
trametinib (Mekinist)
Tretinoin & Vitamin A Analogues (topical)

V
vedolizumab (Entyvio) - Medical Benefit Drug
vemurafenib (Zelboraf)
vigabatrin (Sabril)
vismodegib (Erivedge)
voriconazole (Vfend)

Z
zoledronic acid intravenous (Reclast) - Medical Benefit Drug


Clarification on PA forms that contain more than one drug

Hereditary Angioedema

  • Berinert (C1 Esterase Inhibitor) – Medical Benefit Drug
  • Cinryze (C1 Esterase Inhibitor) – Medical Benefit Drug
  • Firazyr (icatibant)
  • Kalbitor (ecallantide)—Medical Benefit Drug

Immunoglobulins (IV & SC)

  • Carimune NF (immune globulin) – Medical Benefit Drug
  • Flebogamma (immune globulin) – Medical Benefit Drug
  • Gammagard Liquid (immune globulin) – Medical Benefit Drug
  • Gammagard S/D (immune globulin) – Medical Benefit Drug
  • Gammaplex (immune globulin) – Medical Benefit Drug
  • Gammar-P I.V. (immune globulin) – Medical Benefit Drug
  • Gamunex (immune globulin) – Medical Benefit Drug
  • Hizentra (immune globulin) – Medical Benefit Drug
  • Privigen (immune globulin) – Medical Benefit Drug
  • Vivaglobin (immune globulin) – Medical Benefit Drug

Multiple Sclerosis Interferons

  • Betaseron (interferon beta-1b)
  • Extavia (interferon beta-1b)
  • Rebif (interferon beta-1a)

Oral and Infused Cancer Medications 
(may not be a comprehensive list -- list may change at any time for any reason) 
Afinitor, Alkeran, Bosulif, capecitabine, Caprelsa, Cetuximab, Cometriq, Emcyt, Erivedge, etoposide, exemestane, Fareston, Gleevec, Gilotrif, Hexalen, Hycamtin, Iclusig, Imbruvica, Inlyta, Jakafi, Leukeran, Lomustine, Lysodren, Matulane, Myleran, Nexavar, Nilandron, Pembrolizumab, Pomalyst, Purixan, Ramucirumab, Revlimid, Siltuximab, Soltamox, Sprycel, Stivarga, Sutent, Tabloid, Tarceva, Targretin, Tasigna, temozolomide, Thalomid, Tretinoin, Tykerb, Votrient, Xalkori, Xtandi, Zolinza, Zykadia, Zytiga

Testosterone Replacement

  • Androderm (testosterone transdermal)
  • Androgel (testosterone gel)
  • Testim (testosterone gel)

TNF Inhibitor

  • Humira (adalimumab)
  • Cimzia (certolizumab)

Tretinoin and Vitamin A Analogues (topical)

  • Avita (tretinoin 0.025%)
  • Azelex (azelaic acid 20%)
  • Differin (adapalene)
  • Finacea (azelaic acid 15%)
  • Renova (tretinoin 0.02%)
  • Retin-A-Micro (tretinoin)
  • Tretinoin, generic