Prior Authorization for Pharmacy - Good Health Plans

Prior Authorization for Pharmacy - Good Health Plans

Good Health 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

Actemra (tocilizumab) IV

Actemra (tocilizumab) SubQ

Adcetris (brentuximab_vedotin)

Adcirca (tadalafil)

Adempas (riociguat)

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


Aimovig (erenumab-aooe)

Ajovy (fremanezumab)

Apokyn (apomorphine)

Arcalyst (rilonacept)

Arzerra (ofatumumab)

Austedo (deutetrabenazine)

Avastin (bevacizumab)

top

B

Bavencio (avelumab)

Beleodaq (belinostat)

Bendeka (bendamustine)

Benlysta (belimumab)

Blincyto (blinatumomab)

Bosulif (bosutinib)

Botox (botulinum toxin)

Butrans (buprenorphine)

top

C

Cabometyx (cabozantinib)

Caprelsa (vandetanib)

Carbaglu (carglumic acid)

Caverject or Edex (alprostadil)

Cimzia (certolizmab pegol)

Cinryze (C1 esterase inhibitor)

Cometriq (cabozantinib)

Cosentyx (secukinumab)

Cotellic (cobimetinib)

Cyramza (ramucirumab)

 

top

D

Darzalex (daratumumab)

Daurismo (glasdegib maleate)

Desoxyn (methamphetamine)

Dificid (fidaxomicin)

Dupixent (dupilmab)

Dysport (abobotulinumtoxinA)

 

top

E

Emgality (galcanezumab-gnlm)

Empliciti (elotuzumab)

Enbrel (etanercept)

Entyvio (vedolizumab)

Epclusa (sofosbuvir velpatasvir)

Epidiolex  (cannabidiol)

Erbitux (cetuximab)

Erivedge (vismodegib)

Erleada (apalutamide)

Esbriet (pirfenidone)

Evenity (romosozumab appg)

Exjade (deferasirox)

Eylea (aflibercept)

top

F

Farydak (panobinostat)

Fasenra (benralizumab)

Faslodex (fulvestrant)

Ferriprox (deferiprone)

Firazyr (icatibant)

Folotyn (pralatrexate)

Forteo (teriparatide)

Fusilev (levoleucovorin)

top

G

Gazyva (obinutuzumab)

Gilotrif (afatinib)

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

Growth Hormone

top

H

Halaven (eribulin)

Harvoni (ledipasvir/sofosbuvir)

Humira (adalimumab)


top

I

Ibrance (palbociclib)

Iclusig (ponatinib)

Ilaris (canakinumab)

Imbruvica (ibrutinib)

Imfinzi (durvalumab)

Increlex (mecasermin)

Infertility

Inflectra (infliximab-dyyb)

Ingrezza (valbenazine)

Inlyta (axitinib)

Iprivask (desirudin)

Istodax (romidepsin)

Ixempra (ixabepilone)

top

J

Jadenu (deferasirox)

Jakafi (ruxolitimid)

Jetrea (ocriplasmin)

Jevtana (cabazitaxel)

Jynarque (tolvaptan)

top

K

Kadcyla (ado-trastuzumab)

Kalbitor (escallantide)

Kalydeco (ivacaftor)

Kevzara (sarilumab)

Keytruda (pembrolizumab)

Kineret (anakinra)
 
Korlym (mifepristone)

Krystexxa (pegloticase)

Kuvan (sapropterin)

Kymriah (tisagenlecleucel)

Kyprolis (carfilzomib)

top

L

Lazanda (fentanyl Nasal Spray)

Lenvima (lenvatinib)

Letairis (ambrisentan)

Lonsurf (trifluridine tipiracil)

Lotronex (alosetron)

Lucentis (ranibizumab)

Lynparza (olaparib)

top

M

Makena (hydroxyprogesterone caproate injection)

Mavyret (glecaprevir pibrentasvir)

Marqibo (vincristine sulfate LIPOSOMAL injection)

Mekinist (trametinib dimethyl sulfoxide)

Myobloc (rimabotulinumtoxinB)

top

N

Nexavar (sorafenib)

Ninlaro (ixazomib)

Northera (droxidopa)

Nucala (mepolizumab)

top

O

Ofev (nintedanib)

Opdivo (nivolumab)

Opsumit (macitentan)

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

Orencia (abatacept)

Orenitram (treprostinil)

top

P

Perjeta (pertuzumab)

Pomalyst (pomalidomide)

Praluent (alirocumab)

Proferrin (heme iron poly)

Prolia (denosumab)

Provenge (sipuleucel-T)

top

R

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

Remicade (infliximab)

Remodulin (treprostinil)

Renflexis (infliximab-abda)

Repatha (evolocumab)

Revatio (sildenafil)

Revlimid (lenalidomide)

Rinvoq (upadacitinib)

Rubraca (rucaparib)

top

S

Sabril (vigabatrin)

Sancuso (granisetron patch)

Serostim (somatropin, mammalian derived)

Siliq (brodalumab)

Simponi (golimumab)

Simponi ARIA (golimumab)

Skyrizi (risankizumab-rzaa)

Somatuline Depot (lanreotide)

Somavert (pegvisomant)

Sovaldi (sofosbuvir)

Spravato (esketamine)

Sprycel (dasatinib)

Stelara (ustekinumab)

Stivarga (regorafenib)

Sutent (sunitinib)

Sylvant (siltuximab)

Synagis (palivizumab)

Synribo (omacetaxine mepesuccinate)

top

T

Tafinlar (dabrafenib)

Tagrisso (osimertinib)

Taltz (ixekizumab)

Tarceva (erlotinib)

Tasigna (nilotinib)

Tecentriq (atezolizumab)

Torisel (temsirolimus)

Tracleer (bosentan)

Transmucosal Fentanyl (fentanyl citrate lillipop, Fentora)

Treanda (bendamustine)

Triptans (Anti-migraine)

Tremfya (guselkumab)

Tykerb (lapatinib)

Tymlos (abaloparatide)

Tysabri (natalizumab)

Tyvaso (treprostini)

top

U

 Uceris (budesonide)

top

V

Valchlor (mechlorethamine)

Vectibix (panitumumab)

Venclexta (venetoclax)

Ventavis (iloprost trometamol)

Verzenio (abemaciclib)

Vosevi (sofosbuvir velpatasvir voxilapervir)

Votrient (pazopanib)

 

top

X

Xalkori (crizotinib)

Xeljanz (tofacitinib)

Xenazine (tetrabenazine)

Xeomin (incobotullnumtoxinA)

XGEVA (denosumab)

Xiaflex (collagenase clost hist)

Xofigo (radium Ra 223)

Xolair (omalizumab)

Xtandi (enzalutamide)

Xyrem (sodium oxybate)

top

Y

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)

top

Z

Zavesca (miglustat)

Zelboraf (vemurafenib)

Zejula (niraparib)

Zepatier (elbasvir grazoprevir)

Zinplava (bezlotoxumab)

Zolinza (vorinostat)

Zorbtive (somatropin)

Zydelig (idelalisib)

Zykadia (ceritinib)

Zytiga (abiraterone acetate)

top