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Legal Notices: Health benefits and health insurance plans contain exclusions and limitations.

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Applications and forms for health care professionals and their patients.

Part D prescription drug prior authorizations and exceptions

General Prior Authorization

Aranesp® (darbepoetin alfa)

Lidocaine Products

Linezolid (generic Zyvox®)

Modafinil (generic Provigil®) and Armodafinil

Ondansetron (oral generic Zofran®)

Procrit® (epoetin alfa)

Regranex® (becaplermin)

Sildenafil (generic Revatio®)

Topical testosterone

Tracleer® (bosetan)

Zolpidem (generic Ambien®)

Tier exception (cost-share reduction) request

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Page last updated: Mon Feb 15 14:38:50 EST 2021