Drug Prior Authorization Forms

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



Standard Prior Authorization Request:
Medication PA Request Form


Forms listed alphabetically by their brand name

A
Actemra (tocilizumab) – Medical Benefit Drug
Acthar Gel (repository corticotropin)
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
Bydureon (exenatide LAR)
Byetta (exenatide)

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

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

E
Eliquis (apixaban)
Entocort EC (budesonide)
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
Growth Hormone - Initiation
Growth Hormone - Continuation

H
Hereditary Angioedema
Hizentra (immune globulin) - Medical Benefit Drug
Humira (adalimumab)

I
Ilaris (canakinumab) – Medical Benefit Drug
Immunoglobulin (IV & SC) - Medical Benefit Drug
Incivek (telaprevir)
Incretin Mimetics
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)
Myrbetriq (mirabegron)

N
Noxafil (posaconazole)
Nplate (romiplostim)

O
Onfi (clobazam)
Orencia (abatacept) - Medical Benefit Drug
Oxandrin (oxandrolone)

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

R
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)
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

U
Uloric (febuxostat)

V
Vfend (voriconazole)
Victoza (liraglutide)
Victrelis (boceprevir)
Vimpat (lacosamide)
Vivaglobin (immune globulin) - Medical Benefit Drug

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

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)
apixaban (Eliquis)
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
dabigatran (Pradaxa)
dabrafenib (Tafinlar)

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

E
ecallantide (Kalbitor) - Medical Benefit Drug
eltrombopag (Promacta) 
exenatide (Byetta)
exenatide LAR (Bydureon)
ezogabine (Potiga)

F
febuxostat (Uloric)
fidaxomicin (Dificid)
fingolimod (Gilenya)

G
Glucose Test Strip Quantity Limit
Growth Hormone - Initiation
Growth Hormone - Continuation
guanfacine (Intuniv)

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

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

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

N
natalizumab (Tysabri) - Medical Benefit Drug

O
olopatadine ophthalmic (Patanol)
omalizumab (Xolair) - Medical Benefit Drug
omega-3-acids (Lovaza)
oxandrolone (Oxandrin)

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

R
repository corticotropin (Acthar Gel)
rilonacept (Arcalyst) – Medical Benefit Drug
rituximab (Rituxan) - Medical Benefit Drug
rivaroxaban (Xarelto) for stroke prevention
rivaroxaban (Xarelto) 
roflumilast (Daliresp)
romiplostim (Nplate)
rufinamide (Banzel)

T
telaprevir (Incivek)
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
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

Incretin Mimetics (Diabetes)

  • Byetta (exenatide)
  • Victoza (liraglutide)

Multiple Sclerosis Interferons

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

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