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MEDICAL DRUG PRIOR AUTHORIZATION FOR MEDICAID AND CHP+ PLANS

MEDICAL DRUG PRIOR AUTHORIZATION FOR MEDICAID AND CHP+ PLANS

Medicaid and CHP+ Prior Authorization Forms for drugs received from a doctor

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.

For Medicaid and CHP+ Pharmacy Drug Prior Authorization, visit professionals.optumrx.com.

 

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

Adcetris (brentuximab_vedotin)

Apokyn (apomorphine)

Arzerra (ofatumumab)

Avastin (bevacizumab)

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B

Bavencio (acelumab)

Beleodaq (belinostat)

Bendeka (bendamustine)

Benlysta (belimumab)

Blincyto (blinatumomab)

Botox (botulinum toxin)

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C

Cabometyx (cabozantinib)

Cometriq (cabozantinib)

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D

Darzalex (daratumumab)

Dysport (abobotulinumtoxinA)

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E

Empliciti (elotuzumab)

Entyvio (vedolizumab)

Evenity (romosozumab appg)

Eylea (aflibercept)

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F

Farydak (panobinostat)

Fasenra (benralizumab)

Folotyn (pralatrexate)

Fusilev (levoleucovorin)

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G

Gazyva (obinutuzumab)

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H

 

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I

Ilaris (canakinumab)

Imfinzi (durvalumab)

Inflectra (infliximab-dyyb)

Iprivask (desirudin)

Istodax (romidepsin)

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J

Jadenu (deferasirox)

Jetrea (ocriplasmin)

Jevtana (cabazitaxel)

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K

Kadcyla (ado-trastuzumab)

Kalbitor (escallantide)

Keytruda (pembrolizumab)

Kineret (anakinra)
 
Krystexxa (pegloticase)

Kymriah (tisagenlecleucel)

Kyprolis (carfilzomib)

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L

Lucentis (ranibizumab)

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M

Makena (hydroxyprogesterone caproate injection)

Marqibo (vincristine sulfate LIPOSOMAL injection)

Myobloc (rimabotulinumtoxinB)

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N

Nucala (mepolizumab)

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O

Opdivo (nivolumab)

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

Orencia (abatacept)

Orenitram (treprostinil)

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P

Perjeta (pertuzumab)

Pomalyst (pomalidomide)

Praluent (alirocumab)

Proferrin (heme iron poly)

Prolia (denosumab)

Provenge (sipuleucel-T)

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R


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

Remicade (infliximab)

Remodulin (treprostinil)

Renflexis (infliximab-abda)

Repatha (evolocumab)

Revatio (sildenafil)

Revlimid (lenalidomide)

Reyvow (lasmiditan)

Rubraca (rucaparib)

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S

Sabril (vigabatrin)

Sancuso (granisetron patch)

Serostim (somatropin, mammalian derived)

Siliq (brodalumab)

Simponi (golimumab)

Simponi ARIA (golimumab)

Sinuva (mometasone furoate nasal implant)

Somatuline Depot (lanreotide)

Somavert (pegvisomant)

Sovaldi (sofosbuvir)

Spravato (esketamine)

Sprycel (dasatinib)

Stelara (ustekinumab)

Stivarga (regorafenib)

Sutent (sunitinib)

Sylvant (siltuximab)

Synagis (palivizumab)

Synribo (omacetaxine mepesuccinate)

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T

Tafinlar (dabrafenib)

Tagrisso (osimertinib)

Taltz (ixekizumaub)

Tarceva (erlotinib)

Tasigna (nilotinib)

Tecentriq (atezolizumab)

Torisel (temsirolimus)

Tracleer (bosentan)

Transmucosal Fentanyl (fentanyl citrate lillipop, Fentora)

Treanda (bendamustine)

Tremfya (guselkumaub)

Triptans (Anti-migraine)

Tykerb (lapatinib)

Tymlos (abaloparatide)

Tysabri (natalizumab)

Tyvaso (treprostini)

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U

Ubrelvy (ubrogepant) 

Uceris (budesonide)

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V

Valchlor (mechlorethamine)

Vectibix (panitumumab)

Venclexta (venetoclax)

Ventavis (iloprost trometamol)

Verzenio (abemaciclib)

Vosevi (sofosbuvir velpatasvir voxilapervir)

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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Y

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)
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Z

Zavesca (miglustat)

Zelboraf (vemurafenib)

Zejula (niraparib)

Zepatier (elbasvir grazoprevir)

Zinplava (bezlotoxumab)

Zolinza (vorinostat)

Zorbtive (somatropin)

Zydelig (idelalisib)

Zykadia (ceritinib)

Zytiga (abiraterone acetate)

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