Members with an urgent life-threatening medication prior authorization request please contact Pharmacy Services directly at (608) 260-7803 or fax (608) 327-0324, Monday through Friday before 5 p.m.


For assistance outside of regular business hours or holidays, please leave a detailed voicemail or submit a prior authorization form clearly marked "Urgent" or "Expedited."


Forms listed alphabetically by their brand name.

 A

Actemra SC (tocilizumab)
Acthar Gel (repository corticotropin)
Adempas (riociguat)
Aimovig
Amitiza (lubiprostone)
Ampyra (dalfampridine)
Androgel (testosterone gel)
Androderm (testosterone transdermal)
Apokyn (apomorphine)
Aralast NP (alpha-1 proteinase inhibitor) – Medical Benefit Drug
Arcalyst (rilonacept) – Medical Benefit Drug
Atrigel (leuprolide) – Medical Benefit Drug
Avita (tretinoin 0.025%)
Axiron (testosterone solution)

 N

Neulasta (Pegfilgrastim) – Medical and Pharmacy Benefit Drug
Novarel (Human Chorionic Gonadotropin/Clomiphene)- Medical Benefit Drug
Noxafil (posaconazole)
Nplate (romiplostim)
Nucala (mepolizumab) for Asthma
Nucala (mepolizumab) for EGPA
Nucala (mepolizumab) – Medical Benefit Drug

 

B

Banzel (rufinamide)
Baxdela (Delafloxacin)
Benlysta (belimumab)– Medical Benefit Drug
Berinert (C1 Esterase Inhibitor) – Medical Benefit Drug - PA for Prophylaxis
Botox (Botulinum toxin)

O

Ocrevus (ocrelizumab) – Medical and Pharmacy Benefit Drug
Odactra (house dust mite allergen)
Onfi (clobazam)
Orafate (Polymerized Sucralfate)
Oral and Infused Cancer Medications
Oral and Self-Injectable MS Medications
OramagicRx (Bioadhesive Gel)
Orencia (Abatacept)
Opsumit (macitentan)
Oralair (five-grass pollen allergen)
Orkambi (ivacaftor / lumacaftor)
Otezla (apremilast) – Indication Based
Oxandrin (oxandrolone)

C

Cayston (aztreonam lysine Inhalation Solution)
Cerdelga (eliglustat)
Cerezyme (imiglucerase) – Medical Benefit Drug
Cimzia (Certolizumab)
Cinquair (reslizumab) – Medical Benefit Drug
Cinryze (C1 Esterase Inhibitor)– Medical Benefit Drug - PA for Prophylaxis
Compounds (>$100)
Constipation Agents
Corlanor (ivabradine)
Cosentyx (secukinumab) – Indication Based
Crinone
Crysvita – Medical Benefit Drug

P

Palynzig
Patanol (Olopatadine ophthalmic)
Pataday (Olopatadine ophthalmic)
Potiga (ezogabine)
Pregnyl (Human Chorionic Gonadotropin/Clomiphene) - Medical Benefit Drug
Primary Prevention of Breast Cancer Medication
Probuphine (Buprenorphine Implant) – Medical Benefit Drug
Prolastin C (alpha-1 proteinase inhibitor) – Medical Benefit Drug
Prolia (denosumab) – Medical Benefit Drug
Promacta (eltrombopag)
Prothelial (Polymerized Sucralfate)

D

Dexcom Personal CGM
Differin (adapalene)
Dificid (fidaxomicin)
Doptelet (avatrombopag)
Dysport (Botulinum toxin)

R

Radicava (Edaravone) - Medical Benefit Drug
Ragwitek (short ragweed pollen allergen extract)
Rebif (interferon beta 1-a)
Regranex (becaplermin)
Relistor (methylnaltrexone)
Remicade (infliximab) – Medical Benefit Drug
Renflexis (Infliximab-abda) – Medical Benefit Drug
Renova (tretinoin 0.02%)
Repatha (evolocumab)
Restasis (cyclosporine ophthalmic)
P5475-Tretinoin-VitaminA (1)
Ruconest (C1 Esterase Inhibitor Recomb) – Medical Benefit Drug - PA for Prophylaxis
Rytary (carbidopa/levodopa ER)

E

Elelyso (taliglucerase alfa)– Medical Benefit Drug
Eligard (leuprolide)
Emsam Patch (selegilene)
Enbrel (etanercept) – Indication Based
Endometrin
Entocort EC (budesonide)
Entresto (sacubitril/valsartan)
Entyvio (vedolizumab) – Medical Benefit Drug
Episil (Bioadhesive Gel)
Erivedge (vismodegib)

 

S

Sabril (vigabatrin)
Samsca (tolvaptan)
Savella (milnacipran)
Simponi (Golimumab)
Soliris (Eculizumab)– Medical Benefit Drug
Spinraza (nusinersin) – Medical Benefit Drug
Stelara (ustekinumab) – Indication Based
Strensiq (asfotase alfa)
Striant (testosterone buccal)
Sublocade Subcutaneous inj – Medical Benefit Drug
Supprelin LA (histrelin) – Medical Benefit Drug
Symdeko (ivacaftor / tezacaftor)
Synagis (palivizumab) – Medical Benefit Drug

F

Fanapt (iloperidone)
Fasenra (Benralizumab) – Medical Benefit Drug
Fasenra (Benralizumab)
Firazyr (icatibant)– PA for Prophylaxis
Forteo (teriparatide)

T

Taclonex (betamethasone dipropionate 0.064% calcipotriene 0.005%)
Tafinlar (dabrafenib)
Tafinlar (dabrafenib)
Tavalisse (Fostamatinib)
Testim (testosterone gel)
Testosterone Injections – Medical Benefit Drug 
Tikosyn (dofetilide)
Topical Mucosal Protectants
Tracleer (bosentan)
Tremfya (guselkumab)
Tretinoin & Vitamin A Analogues (topical)
Triptodur, Trelstar (triptorelin) – Medical Benefit Drug
Tysabri (natalizumab) – Medical Benefit Drug

G

Gelclair (Bioadhesive Gel)
Glassia (alpha-1 proteinase inhibitor) – Medical Benefit Drug
Glucose Test Strip Quantity Limit
Gocovri (Amantadine ER)
Grastek (grass pollen allergen)
Growth Hormone - Initiation
Growth Hormone - Continuation
Guardian Personal CGM

U

Ultram (tramadol) Age < 11 y.o.

H

Haegarda (C1 Esterase Inhibitor) – PA for Prophylaxis
Hemlibra (emcizumab-kxwh)
Hepatitis C
Hereditary Angioedema
Human Chorionic Gonadotropin/Clomiphene (Novarel, Pregnyl) - Medical Benefit Drug
Humira (adalimumab)

V

Vantas Preferred (histrelin) - Medical Benefit Drug – Medical Benefit Drug
Vfend (voriconazole)
Vimpat (lacosamide)
Vivitrol (naltrexone IM) – Medical and Pharmacy Benefit Drug

I

Ilaris (canakinumab) – Medical Benefit Drug 
Inflectra (Infliximab-dyyb) - Medical Benefit Drug
Invega (paliperidone)

X

Xadago (safinamide)
Xeljanz (tofacitinib) – Indication Based
Xenazine (tetrabenazine)
Xeomin (Botulinum toxin)
XGEVA (denosumab) – Medical Benefit Drug
Xiidra (lifitegrast ophthalmic)
Xifaxan (Rifaximin) – Pharmacy Benefit Drug
Xolair (omalizumab) – Medical Benefit Drug

K

Kalbitor (ecallantide) – Medical Benefit Drug - PA for Prophylaxis
Kanuma (sebelipase alfa)  Medical Benefit Drug
Kepivance (palifermin)
Kevzara (Sarilumab)
Kineret (Anakinra)

Y

Yervoy (ipilimumab) – Medical Benefit Drug

L

Latuda (lurasidone)
Lemtrada (alemtuzumab)  Medical Benefit Drug
Letairis (ambrisentan)
Linzess (linaclotide)
Lovaza (omega-3-acids)
Lumizyme (alglucosidase alfa)  Medical Benefit Drug
Lupron (leuprolide) – Medical and Pharmacy Benefit Drug
Lyrica (pregabalin)

Z

Zavesca (miglustat)
Zelboraf (vemurafenib)
Zemaira (alpha-1 proteinaise inhibitor) – Medical Benefit Drug
Zenpep (pancrelipase)
Zinplava (bezlotoxumab) – Benefit Drug

M

Makena  Medical Benefit Drug
Medications with Miscellaneous Codes (J3490, J3590) – Medical Benefit Drug
Medtronic Personal CGM
Mekinist (trametinib)
Metozolv ODT (metoclopramide)
Movantik (naloxegol)
Multiple Sclerosis (interferons)  Medical and Pharmacy Benefit Drug
Myobloc (Botulinum toxin)

  

This health plan is underwritten by Physicians Plus Insurance, Inc.