fall-leaves-against-a-blue-sky fall-leaves-against-a-blue-sky

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.

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


Medicare Part B Prior Authorization Forms

Adakveo (crizanlizumab)

Crysvita (burosumab-twza)

Givlaari

Kymriah (tisagenlecleucel)

Luxterna (voretigene-neparvovec-rzyl)

Onpattro (patisiran)

Radicava (edaravone)

Reblozyl

Soliris (eculizumab)

Spinraza (nusinersen)

Tecartus (brexucabtagene autoleucel)

Tepezza

Uplinza

Yescarta (axicabtagene ciloleucel)

Zolgensma