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Medical Drug Prior Authorization for Individual and Family Plans

Individual & Family 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

Actimmune (interferon gamma-1b)

Adcetris (brentuximab_vedotin)

Advate (antihemophilic factor [recombinant])

Adynovate (antihemophilic factor [recombinant], pegylated)

Afstyla (antihemophilic factor [recombinant], single chain)


Amondys 45 (casimersen)

Arikayce (amikacin liposome inhalation suspension)

Arzerra (ofatumumab)

Avastin (bevacizumab)

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B

Beleodaq (belinostat)

Bendeka (bendamustine)

Blincyto (blinatumomab)

Botox (botulinum toxin)

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C

Cabenuva (long-acting-injectable-antiretroviral-agents)

Cimzia (certolizmab pegol)

Cyramza (ramucirumab)

 

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D

Doptelet (avatrombopag)

Duopa (carbidopa-levodopa)

Dysport (abobotulinumtoxinA)

 

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E

Egrifta (tesamorelin for injection)

Eligard (leuprolide)

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

Empliciti (elotuzumab)

Entyvio (vedolizumab)

Erbitux (cetuximab)

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F

Faslodex (fulvestrant)

Fensovi (gonadotropin-releasing-hormone-analogs )

Fusilev (levoleucovorin)

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G

Gazyva (obinutuzumab)

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H

H.P. Acthar Gel (repository corticotropin injection)

Helixate FS (antihemophilic factor [recombinant])

Hycamtin (topotecan)

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I

Ilumya (tildrakizumab-asmn)

Imfinzi (durvalumab)

Inflectra (infliximab-dyyb)

intravitreal-corticosteroid-implants

Istodax (romidepsin)

Ixempra (ixabepilone)

Ixinity (coagulation factor IX [recombinant])

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J

Jevtana (cabazitaxel)

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

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K

Kadcyla (ado-trastuzumab)

Keytruda (pembrolizumab)

Kineret (anakinra)

Krystexxa (pegloticase)

Kymriah (tisagenlecleucel)

Kyprolis (carfilzomib)

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L

Lucentis (ranibizumab)

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M

Marqibo (vincristine sulfate LIPOSOMAL injection)

Myobloc (rimabotulinumtoxinB)

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N

 

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O

Opdivo (nivolumab)

Orencia (abatacept)

Oxlumo (lumasiran)

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P

Perjeta (pertuzumab)

Prolia (denosumab)

Provenge (sipuleucel-T)

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R

Recombinate (antihemophilic factor [recombinant])

Remicade (infliximab)

Renflexis (infliximab-abda)

Revatio (sildenafil)

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S

Simponi ARIA (golimumab)

Spravato (esketamine)

Stelara (ustekinumab)
 
Synagis (palivizumab)

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T

Tecentriq (atezolizumab)

Temodar (temozolomide)

Torisel (temsirolimus)

Treanda (bendamustine)

Tysabri (natalizumab)

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U

 
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V

Ventavis (iloprost trometamol)

 
 
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X

Xeomin (incobotullnumtoxinA)

XGEVA (denosumab)

Xiaflex (collagenase clost hist)

Xofigo (radium Ra 223)

Xolair (omalizumab)

Xyntha (antihemophilic factor [recombinant])

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Y

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)

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Z

Zinbryta (daclizumab)

Zinplava (bezlotoxumab)

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