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Medical Drug Prior Authorization Forms for Medicare Part B (DualCare Plus/CareAdvantage)

Medicare Part B Prior Authorization Forms

Rocky Mountain Health Plans covers these drugs for Medicare Part B only as part of a physician visit for DualCare Plus and CareAdvantage members.  For information regarding your Part D coverage, please see our Learning Center.

RMHP is part of the UnitedHealthcare family of plans. We utilize the UnitedHealthcare Commercial guidelines for coverage of these drugs.

Medicare - Drug PA List

Medicare Part B Prior Authorization Forms

Adakveo (crizanlizumab)

Crysvita (burosumab-twza)


Kymriah (tisagenlecleucel)

Luxterna (voretigene-neparvovec-rzyl)

Onpattro (patisiran)

Radicava (edaravone)


Soliris (eculizumab)

Spinraza (nusinersen)

Tecartus (brexucabtagene autoleucel)



Yescarta (axicabtagene ciloleucel)