Commercial and Medicaid Prior Authorization Forms

 

Rocky Mountain cannot process prior authorization requests unless the physician sends clinical notes and indicated test results.  Failure to send clinical notes and test results will result in a timely denial of your request per Colorado State law.

 

A 

B 

C 

D 

E 

F 

G 

H 

I 

J 

K 

L 

M 

N 

O 

P 

R 

S 

T 

U 

V 

X 

Z 


A

Actemra (tocilizumab) IV

Actemra (tocilizumab) SubQ

Adcetris (brentuximab_vedotin)

Adcirca (tadalafil)

Adempas (riociguat)

Afinitor (everolimus) and Afinitor Disperz (everolimus tablets for oral susp)

Apokyn (apomorphine)

Arcalyst (rilonacept)

Arzerra (ofatumumab)

Avastin (bevacizumab)

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B

Beleodaq (belinostat)

Benlysta (belimumab)

Blincyto (blinatumomab)

Bosulif (bosutinib)

Botox Myobloc (Botulinum toxin)

Butrans (buprenorphine)

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C

Caprelsa (vandetanib)

Carbaglu (carglumic acid)


Caverject or Edex (alprostadil)

Cimzia (certolizmab pegol)

Cinryze (C1 esterase inhibitor)

Cometriq (cabozantinib)

Cotellic (cobimetinib)

Cyramza (ramucirumab)

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D

Darzalex (daratumumab)

Desoxyn (methamphetamine)

Dificid (fidaxomicin)

Duragesic (fentanyl)

Dysport (abobotulinumtoxinA)

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E

Empliciti (elotuzumab)

Enbrel (etanercept)

Entyvio (vedolizumab)


Erbitux (cetuximab)

Erivedge (vismodegib)

Esbriet (pirfenidone)

Exjade (deferasirox)

Eylea (afilbercept)

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F

Farydak (panobinostat)

Faslodex (fulvestrant)

Ferriprox (deferiprone)

Firazyr (icatibant)

Folotyn (pralatrexate)


Forteo (teriparatide)

Fusilev (levoleucovorin)



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G

Gazyva (obinutuzumab)

Gilotrif (afatinib)

Grastek (Timothy graa [Phleum pratense] pollen allergen extract)

Growth Hormone

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H

Halaven (eribulin)

Harvoni (ledipasvir/sofosbuvir)

Humira (adalimumab)

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I

Ibrance (palbociclib)

Iclusig (ponatinib)

Ilaris (canakinumab)

Imbruvica (ibrutinib)

Infertility

Increlex (mecasermin)

Inlyta (axitinib)

Iprivask (desirudin)

Istodax (romidepsin)

Ixempra (ixabepilone)

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J

Jakafi (ruxolitimid)

Jetrea (ocriplasmin)

Jevtana (cabazitaxel)

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K

Kadcyla (ado-trastuzumab)

Kalbitor (escallantide)

Kalydeco(ivacaftor)

Keytruda (pembrolizumab)

Kineret (anakinra)
 
Korlym (mifepristone)

Krystexxa (pegloticase)

Kuvan (sapropterin)

Kyprolis (carfilzomib)

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L

Lazanda (fentanyl Nasal Spray)

Lenvima (lenvatinib)

Letairis (ambrisentan)

Lonsurf (trifluridine tipiracil)

Lotronex (alosetron)

Lucentis (ranibizumab)

Lynparza (olaparib)

Lyrica (pregabalin)


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M

Makena (hydroxyprogesterone caproate injection)

Marqibo (vincristine sulfate LIPOSOMAL injection)

Mekinist (trametinib)

 

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N

Nexavar (sorafenib)

Ninlaro (ixazomib)

Northera (droxidopa)

Nucala (mepolizumab)

Nucynta (tapentadol)

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O

Ofev (nintedanib)

Opdivo (nivolumab)

Opsumit (macitentan)

Oralair

Orencia (abatacept)

Orenitram (treprostinil)

OTC Rx Nicotine Replacement

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P

Perjeta (pertuzumab)

Pomalyst (pomalidomide)

Praluent (alirocumab)

Proferrin (heme iron poly)

Prolia (denosumab)


Provenge (sipuleucel-T)

Provigil (modafinil)

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R

Ragwitek

Remicade (infliximab)

Remodulin (treprostinil)

Repatha (evolocumab)

Revatio (sildenafil)

Revlimid (lenalidomide)

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S

Sabril (vigabatrin)

Sancuso (granisetron patch)


Serostim (somatropin, mammalian derived)

Simponi (golimumab)

Simponi ARIA (golimumab)

Soliris (eculizumab)

Somatuline Depot


Somavert (pegvisomant)

Sovaldi (sofosbuvir)

Sprycel (dasatinib)

Stelara (ustekinumab)

Stivarga (regorafenib)

Sutent (sunitinib)

Sylvant (siltuximab)

Synagis (palivizumab)

Synribo (omacetaxine mepesuccinate)

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T

Tafinlar (dabrafenib)

Tagrisso (osimertinib)

Tarceva (erlotinib)

Tasigna (nilotinib)

Torisel (temsirolimus)

Tracleer (bosentan)

Transmucosal Fentanyl

Treanda (bendamustine)

Triptans (Anti-migraine)

Tykerb (lapatinib)

Tysabri (natalizumab)

Tyvaso (treprostini)

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U

 Uceris (budesonide)

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V

Valchlor (mechlorethamine)

Vectibix (panitumumab)

Ventavis (iloprost trometamol)

Votrient (pazopanib)

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X

Xalkori (crizotinib)

Xeljanz (tofacitnib)

Xenazine (tetrabenazine)

Xeomin (incobotullnumtoxinA)

XGEVA (denosumab)

Xiaflex (collagenase clost hist)

Xofigo (radium Ra 223)

Xolair (omalizumab)

Xtandi (enzalutamide)

Xyrem (sodium oxybate)

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Z

Zavesca (miglustat)

Zelboraf (vemurafenib)

Zolinza (vorinostat)

Zydelig (idelalisib)

Zykadia (ceritinib)

Zytiga (abiraterone acetate)

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