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Prior Authorization Rx Advantage Four-Tier

Prior Authorization Rx Advantage Four-Tier

Advantage Four-Tier Rx Prior Authorization Forms

Rocky Mountain Health Plans 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  

Y  

Z  


A

Abilify MyCite (aripiprazole tablet with sensor)

Absorica (isotretinoin)

Abstral (fentanyl sublingual tablets)

Actemra (tocilizumab) IV

Actimmune (interferon gamma-1b)

Actiq (fentanyl transmucosal lozenge)

Adcetris (brentuximab_vedotin)

Adcirca (tadalafil)

Addyi (flibanserin)

Adempas (riociguat)

Advate (antihemophilic factor [recombinant])

Adynovate (antihemophilic factor [recombinant], pegylated)

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

Afrezza (insulin human)

Afstyla (antihemophilic factor [recombinant], single chain)

Aimovig (erenumab-aooe)

Ajovy (fremanezumab)

Albenza (albendazole)

Alecensa (alectinib)

Altreno (tretinoin)

Alunbrig (brigatinib)

Amitiza (lubiprostone)

Amnesteem (isotretinoin)

Ampyra (dalfampridine)

Androderm (testosterone)

Androgel (testosterone)

Aptiom (eslicarbazepine acetate)

Arcalyst (rilonacept)

Arikayce (amikacin liposome inhalation suspension)

Arzerra (ofatumumab)

Atralin (tretinoin)

Aubagio (teriflunomide)

Austedo (deutetrabenazine)

Avastin (bevacizumab)

Avita (tretinoin)

Avonex (interferon-1a)

Axiron (testosterone)

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B

Balversa (erdafitinib)

Banzel (rufinamide)

Belbuca (buprenorphine buccal film)

Beleodaq (belinostat)

Bendeka (bendamustine)

Benlysta (belimumab)

Benznidazole

Berinert (C1 esterase inhibitor, human)

Betaseron (interferon-1b)

Bethkis (tobramycin)

Blincyto (blinatumomab)

Bonjesta (doxylamine-pyrodoxine ER)

Bosulif (bosutinib)

Botox (botulinum toxin)

Braftovi (encorafenib)

Briviact (brivaracetam)

Bunavail (buprenorphine HCL and naloxone)

Butrans (buprenorphine)

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C

Cablivi (caplacizumab-yhdp)

Cabometyx (cabozantinib)

Calquence (acalabrutinib)

Caprelsa (vandetanib)

Carbaglu (carglumic acid)

Cayston (astreonam for inhalation solution)

Cequa (cyclosporine ophthalmic solution)

Cerdelga (eliglustat)

Cholbam (cholic acid)

Cimzia (certolizmab pegol)

Cinryze (C1 esterase inhibitor)

Claravis (isotretinoin)

CNS Stimulant

Cometriq (cabozantinib)

Copaxone (glatiramer acetate)

Copiktra (duvelisib)

Corlanor (ivabradine)

Cosentyx (secukinumab)

Cotellic (cobimetinib)

Cyramza (ramucirumab)

Cystaran (cysteamine)

 

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D

Daliresp (roflumilast)

Daraprim (pyrimethamine)

Darzalex (daratumumab)

Daurismo (glasdegib maleate)

Depakote or Depakote ER (valproic acid)

Diacomit (stiripentol)

Diclegis (doxylamine-pyrodoxine)

Differin (adapalene)

Doptelet (avatrombopag)

Duopa (carbidopa-levodopa)

Dupixent (dupilmab)

Dysport (abobotulinumtoxinA)

 

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E

Egrifta (tesamorelin for injection)

Elidel (pimecrolimus)

Eligard (leuprolide)

Eloctate (antihemophilic factor [recombinant], Fc fusion protein)

Emflaza (deflazacort)

Emgality (galcanezumab-gnlm)

Empliciti (elotuzumab)

Emverm (mebendazole)

Enbrel (etanercept)

Endari (L-glutamine Powder for Solution)

Entresto (valsartan-sacubitril)

Entyvio (vedolizumab)

Epclusa (sofosbuvir velpatasvir)

Epidiolex  (cannabidiol)

Erbitux (cetuximab)

Erivedge (vismodegib)

Erleada (apalutamide)

Esbriet (pirfenidone)

Evzio (naloxone injection)

Exjade (deferasirox)

Extavia (interferon-1b)

Eylea (aflibercept)

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F

Fabior (tazarotene)

Farydak (panobinostat)

Fasenra (benralizumab)

Fentora (fentanyl buccal tablet)

Ferriprox (deferiprone)

Firazyr (icatibant)

Firdapse (amifampridine)

Folotyn (pralatrexate)

Forteo (teriparatide)

Fortesta (testosterone)

Fusilev (levoleucovorin)

Fycompa (perampanel)

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G

Galafold (migalastat)

Gattex (teduglutide (rDNA origin))

Gazyva (obinutuzumab)

Gilenya (fingolimod)

Gilotrif (afatinib)

Glatopa (glatiramer acetate)

Gleevec (imatinib)

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

Growth Hormone

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H

H.P. Acthar Gel (repository corticotropin injection)

Haegarda (C1 esterase inhibitor, human)

Halaven (eribulin)

Harvoni (ledipasvir/sofosbuvir)

Helixate FS (antihemophilic factor [recombinant])

Hemlibra (emicizumab-kxwh)

Hetlioz (tasimelteon)

Humira (adalimumab)

Hycamtin (topotecan)


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I

Ibrance (palbociclib)

Iclusig (ponatinib)

Idhifa (enasidenib)

Ilumya (tildrakizumab-asmn)

Imbruvica (ibrutinib)

Imfinzi (durvalumab)

Impavido (miltefosine)

Inbrija (levodopa inhalation powder)

Increlex (mecasermin)

Inflectra (infliximab-dyyb)

Ingrezza (valbenazine)

Inlyta (axitinib)

Intron A (interferon alfa-2b), Pegasys (peginterferon alfa-2a), PegIntron and Sylatron (peginterferon alfa-2b)

Iressa (gefitinib)

Istodax (romidepsin)

Ixempra (ixabepilone)

Ixinity (coagulation factor IX [recombinant])

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J

Jadenu (deferasirox)

Jakafi (ruxolitimid)

Jatenzo (testosterone)

Jevtana (cabazitaxel)

Jivi (antihemophilic factor [recombinant], PEGylated-aucl)

Jublia (efinaconazole) or Kerydin (tavaborole)

Juxtapid (lomitapide)

Jynarque (tolvaptan)

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K

Kadcyla (ado-trastuzumab)

Kalbitor (escallantide)

Kalydeco (ivacaftor)

Keveyis (dichlorphenamide)

Kevzara (sarilumab)

Keytruda (pembrolizumab)

Kineret (anakinra)

Kisqali  Femara Co-Pack (ribociclib-letrozole)

Kisqali (ribociclib)

Kitabis Pak (tobramycin)
 
Korlym (mifepristone)

Krystexxa (pegloticase)

Kuvan (sapropterin)

Kymriah (tisagenlecleucel)

Kynamro (mipomersen sodium)

Kyprolis (carfilzomib)

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L

Lazanda (fentanyl Nasal Spray)

Lenvima (lenvatinib)

Letairis (ambrisentan)

Lidoderm (lidocaine patches)

Linzess (linaclotide)

Lokelma (sodium zirconium cyclosilicate)

Long acting opiods

Lonhala Magnair (glycopyrrolate nebulized solution)

Lonsurf (trifluridine tipiracil)

Lorbrena (lorlatinib)

Lotronex (alosetron)

Lovaza (omega-3-acid ethyl esters)

Lucemyra (lofexidine)

Lucentis (ranibizumab)

Lynparza (olaparib)

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M

Makena (hydroxyprogesterone caproate injection)

Marqibo (vincristine sulfate LIPOSOMAL injection)

Mavenclad (cladribine)

Mavyret (glecaprevir-pibrentasvir)

Mayzent (siponimod)

Mekinist (trametinib dimethyl sulfoxide)

Mektovi (binimetinib)

Migranal (dihyroergotamine nasal spray)

minocycline ER (generic, Minolira, Solodyne or Ximino)

Motegrity (prucalopride)

Movantik (naloxegol)

Mulpleta (lusutrombopag)

Multaq (dronedarone)

Myalept (metreleptin)

Myobloc (rimabotulinumtoxinB)

Myorisan (isotretinoin)

Mytesi (crofelemer)

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N

Natesto (testosterone)

Natpara (parathyroid hormone analog)

Nerlynx (neratinib)

Nexavar (sorafenib)

Ninlaro (ixazomib)

Nityr (nitisinone)

Nocdurna (desmopressin acetate)

Noctiva (desmopressin acetate)

non-solid oral dosage forms

Northera (droxidopa)

Novarel (chorionic gonadotropin)

Nubeqa (darolutamide)

Nucala (mepolizumab)

Nuedexta (dextromethorphan-quinidine)

Nuplazid (pimavanserin tartrate)

Nuvigil (armodafinil) 

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O

Ocaliva (obeticholic acid)

Odactra (Dermatophagoides Farinae-Dermatophagoides Pteronyssinus Allergan Extract)

Odomzo (sonidegib)

Ofev (nintedanib)

Olumiant (baricitinib)

Onfi or Sympazan (clobazam)

Opdivo (nivolumab)

opioid containing cough medicines

Opsumit (macitentan)

Oralair (sweet vernal, orchard, perennial rye, Timothy, and Kentucky blue grass mixed pollens allergen extract)

Orencia (abatacept)

Orenitram (treprostinil)

Orfadin (nitisinone)

Orilissa (elagolix)

Orkambi (lumacaftor-ivacaftor)

Osphena (ospemifene)

Otezla (apremilast)

Oxervate (cenegermin-bkbj)

Oxistat (oxiconazole)

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P

Palynziq (pegvaliase-pqpz)

Perjeta (pertuzumab)

Piqray (alpelisib)

Plegridy (interferon-1a)

Pomalyst (pomalidomide)

Praluent (alirocumab)

Prevymis (letermovir)

Procysbi (cysteamine bitartrate)

Promacta (eltrombopag)
 
Protopic (tacrolimus)

Provenge (sipuleucel-T)

Provigil (modafinil)

Prudoxin (doxepin)

Pulmozyme (dornase alfa)

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R

Ragwitek (short ragweed [Ambrosia artemisiifolia] pollen allergen extract)

Ravicti (glycerol phenylbutyrate oral liquid)

Rebif (interferon-1a)

Recombinate (antihemophilic factor [recombinant])

Regranex (becaplermin gel)

Relistor (methylnaltrexone bromide)

Remicade (infliximab)

Remodulin (treprostinil)

Renflexis (infliximab-abda)

Repatha (evolocumab)

Restasis (cyclosporine ophthalmic emulsion)

Retin-A (tretinoin)

Retin-A Micro (tretinoin)

Revatio (sildenafil)

Revatio (sildenafil) IV only

Revlimid (lenalidomide)

Rexulti (brexpiprazole)

Rhofade (oxymetazoline)

Rinvoq (upadacitinib)

Ruconest (C1 esterase inhibitor (recombinant))

Ruzurgi (amifampridine)

Rydapt (midostaurin)

Rubraca (rucaparib)

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S

Sabril (vigabatrin)

Samsca (tolvaptan)

Sandostatin (octreotide acetate)

Selzentry (maraviroc)

Sensipar (cinacalcet)

Serostim (somatropin, mammalian derived)

Signifor (pasireotide diaspartate)

sildenafil citrate solution

sildenafil citrate tablet

Siliq (brodalumab)

Simponi (golimumab)

Simponi ARIA (golimumab)

Skyrizi (risankizumab-rzaa)

sodium phylbutyrate (Buphenyl)

Solaraze (diclofenac gel)

Soliqua (insulin glargine-lixisenatide)

Somavert (pegvisomant)

Sovaldi (sofosbuvir)

Spravato (esketamine)

Sprycel (dasatinib)

Stelara (ustekinumab)

Stendra (avanafil)

Stivarga (regorafenib)

Strensiq (asfotase alfa)

Striant (testosterone)

Suboxone Film (buprenorphine HCL and naloxone)

Subsys (fentanyl sublingual spray)

Sucraid (sacrosidase) oral solution

Sunosi (solriamfetol)

Sutent (sunitinib)

Sylvant (siltuximab)

Symdeko (tezacaftor-ivacaftor)

Symproic (naldemedine)

Synagis (palivizumab)

Synribo (omacetaxine mepesuccinate)

Syprine (trientine hydrochloride)

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T

Tafinlar (dabrafenib)

Tagrisso (osimertinib)

Takhzyro (lanadelumab-flyo)

Taltz (ixekizumab)

Talzenna (talazoparib)

Tarceva (erlotinib)

Tasigna (nilotinib)

Tavalisse (fostamatinib)

Tazorac (tazarotene)

Tecentriq (atezolizumab)

Tecfidera (dimethyl fumarate)

Tegsedi (inotersen)

Temodar (temozolomide)

Testim (testosterone)

Thalomid (thalidomide)

Tibsovo (ivosidenib)

TOBI (tobramycin)

Torisel (temsirolimus)

Tracleer (bosentan)

Treanda (bendamustine)

Tremfya (guselkumab)

Tretin-X (tretinoin-cleanser)

Trikafta (elexacaftor-tezacaftor-ivacaftor)

Trintellix (vortioxetine)

Trulance (plecanatide)

Tykerb (lapatinib)

Tymlos (abaloparatide)

Tysabri (natalizumab)

Tyvaso (treprostini)

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U

Ultravate (halobetasol propionate)

Uptravi (selexipag)

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V

Valchlor (mechlorethamine)

Vascepa (icosapent ethyl)

Vecamyl (mecamylamine)

Vectibix (panitumumab)

Veltassa (patiromer)

Venclexta (venetoclax)

Ventavis (iloprost trometamol)

Vermox (mebendazole)

Verzenio (abemaciclib)

Viberzi (eluxadoline)

Vimpat (lacosamide)

Vitrakvi (larotrectinib)

Vizimpro (dacomitinib)

Vogelxo (testosterone)

Vosevi (sofosbuvir velpatasvir voxilapervir)

Votrient (pazopanib)

Vyndamax (tafamidis) Vyndaqel (tafamidis meglumine) 

 

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X

Xadago (safinamide)

Xalkori (crizotinib)

Xeljanz (tofacitinib)

Xenazine (tetrabenazine)

Xeomin (incobotullnumtoxinA)

Xermelo (telotristat ethyl)

XGEVA (denosumab)

Xiaflex (collagenase clost hist)

Xifaxan (rifaximin)

Xiidra (lifitegrast ophthalmic solution)

Xofigo (radium Ra 223)

Xolair (omalizumab)

Xtandi (enzalutamide)

Xuriden (uridine triacetate)

Xyntha (antihemophilic factor [recombinant])

Xyosted (testosterone)

Xyrem (sodium oxybate)

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Y

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)

Yonsa (abiraterone acetate)

Yuperlri (fevefenacin inhalation solution)

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Z

Zejula (niraparib)

Zelboraf (vemurafenib)

Zenatane (isotretinoin)

Zepatier (elbasvir grazoprevir)

Zinbryta (daclizumab)

Zinplava (bezlotoxumab)

Zonalon (doxepin)

Zorbtive (somatropin)

Zovirax (acyclovir)

Zydelig (idelalisib)

Zykadia (ceritinib)

Zytiga (abiraterone acetate)

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