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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

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D

Darzalex (daratumumab)

Dysport (abobotulinumtoxinA)

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E

Empliciti (elotuzumab)

Entyvio (vedolizumab)

Eylea (aflibercept)

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F

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

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)

Orencia (abatacept)

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P

Perjeta (pertuzumab)

Prolia (denosumab)

Provenge (sipuleucel-T)

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R


Remicade (infliximab)

Remodulin (treprostinil)

Renflexis (infliximab-abda)

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S

Simponi ARIA (golimumab)

Stelara (ustekinumab)

Sylvant (siltuximab)

Synagis (palivizumab)

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T

Tecentriq (atezolizumab)

Torisel (temsirolimus)

Treanda (bendamustine)

Tysabri (natalizumab)

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U

 
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V

Vectibix (panitumumab)

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X

Xeomin (incobotulinumtoxinA)

XGEVA (denosumab)

Xiaflex (collagenase clost hist)

Xofigo (radium Ra 223)

Xolair (omalizumab)

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Y

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)
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Z

Zinplava (bezlotoxumab)


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