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Prior Authorization Forms for Pharmacy - D-SNP Part B

Prior Authorization Forms for Pharmacy - D-SNP Part B

D-SNP 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.


D-SNP Part B Forms

Crysvita (burosumab-twza)

Luxturna (voretigene-neparvovec-rzyl)

Onpattro (patisiran)

Radicava (edaravone)

Soliris (eculizumab)

Spinraza (nusinersen)

Ultomiris (ravulizumab-cwvz)

Zolgensma (onasemnogene-abeparvovec-xioi)