Prior Authorization Forms for Pharmacy - Medicare Part B

Prior Authorization Forms for Pharmacy - Medicare Part B

Medicare Part B Prior Authorization Forms

Rocky Mountain Health Plans covers these drugs for Medicare Part B only as part of a physician visit. Drugs may not be obtained through a pharmacy for Medicare. For Members needing to use a pharmacy, please submit your request to your Medicare Part D carrier.


Medicare Part B Forms

Arzerra (ofatumumab)

Entyvio (vedolizumab)

Erbitux (cetuximab)

Eylea (aflibercept)

Halaven (eribulin)

Jetrea (ocriplasmin)

Kadcyla (ado-trastuzumab)

Kalbitor (escallantide)

Krystexxa (pegloticase)

Lucentis (ranibizumab)

Marqibo (vincristine sulfate liposome injection)

Prolia (denosumab)

Provenge (sipuleucel-T)

Soliris (eculizumab)

Testopel (testosterone pellet)

Xiaflex (collagenase clost hist)

Xofigo (radium Ra 223)

Yervoy (ipilimumab)