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Prior Authorization and Step Therapy

Prior Authorization is a tool that helps decide whether or not a prescription is covered before it is filled. The approval or denial is based on the plan design and focuses on safety and proper medication use. If a drug on the Mount Carmel MediGold requires prior authorization, you will see the abbreviation "PA" in the formulary.

Some drugs on the Mount Carmel MediGold formulary will require Step Therapy, a form of prior authorization that requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, your plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, your plan will then cover Drug B. Drugs that require step therapy are marked with an "ST" in the formulary.

You may also see drugs in the formulary marked with "B/D". This means that the drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Please have your pharmacist or doctor call CVS Caremark’s Prior Authorization department at 1-800-294-5979 (TTY 711) before prescribing or administering drugs that require prior authorization or step therapy.

Prior Authorization Criteria (last updated 01/01/2025)

Step Therapy (last updated 10/15/2024)

Prior Authorization Forms

Click any drug name below to view the corresponding prior authorization fax form.

Drugs are listed in alphabetical order. To jump to a specific section, click the letter below that corresponds with the first letter for the drug you are inquiring about:

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

Acitretin 2025 PA Fax 1459-A v1 01-01-25

Actimmune 2025 PA Fax 562-A v1 01-01-25

Adalimumab 2025 PA Fax 107-A v3 01-01-25

Aimovig 2025 PA Fax 3193-A v1 01-01-25

Akeega 2025 PA Fax 6136-A v1 01-01-25

Albendazole 2025 PA Fax 5812-A v1 01-01-25

Aldurazyme 2025 PA Fax 573-A v1 01-01-25

Alecensa 2025 PA Fax 1322-A v2 01-01-25

Alpha-1 Proteinase Inhibitors 2025 PA Fax 11-A v1 01-01-25

Alunbrig 2025 PA Fax 1816-A v1 01-01-25

Alvaiz 2025 PA Fax 6430-A v1 01-01-25

Ambrisentan 2025 PA Fax 640-A v1 01-01-25

Amphetamines 2025 PA Fax 1383-A v1 01-01-25

Ampyra 2025 PA Fax 477-A v1 01-01-25

Ancobon 2025 PA Fax 4603-A v1 01-01-25

Antiemetics 2025 PA Fax BD-16 v1 01-01-25

Arcalyst 2025 PA Fax 597-A v2 01-01-25

Arikayce 2025 PA Fax 2848-A v1 01-01-25

Augtyro 2025 PA Fax 6262-A v2 01-01-25

Austedo 2025 PA Fax 1748-A v1 01-01-25

Auvelity 2025 PA Fax 5576-A v1 01-01-25

Ayvakit 2025 PA Fax 3495-A v1 01-01-25

B

Bafiertam 2025 PA Fax 3884-A v1 01-01-25

Balversa 2025 PA Fax 2966-A v2 01-01-25

Banzel 2025 PA Fax 1386-A v1 01-01-25

Benlysta 2025 PA Fax 862-A v1 01-01-25

Besremi 2025 PA Fax 5062-A v1 01-01-25

Bosulif 2025 PA Fax 806-A v2 01-01-25

Braftovi 2025 PA Fax 2615-A v1 01-01-25

Briviact 2025 PA Fax 4558-A v2 01-01-25

Bronchitol 2025 PA Fax 4340-A v1 01-01-25

Brukinsa 2025 PA Fax 3414-A v4 01-01-25

Budesonide 2025 PA Fax 4498-A v1 01-01-25

C

Cabometyx 2025 PA Fax 1367-A v1 01-01-25

Calquence 2025 PA Fax 2398-A v2 01-01-25

Caprelsa 2025 PA Fax 801-A v1 01-01-25

Carbaglu 2025 PA Fax 840-A v1 01-01-25

Cayston 2025 PA Fax 480-A v1 01-01-25

Cerdelga 2025 PA Fax 1188-A v1 01-01-25

Cerezyme 2025 PA Fax 1497-A v1 01-01-25

Clobazam 2025 PA Fax 1443-A v1 01-01-25

Clomipramine 2025 PA Fax 2484-A v1 01-01-25

Clozapine ODT 2025 PA Fax 1403-A v1 01-01-25

Cobenfy 2025 PA Fax 6685-A v1 01-01-25

Cometriq 2025 PA Fax 916-A v1 01-01-25

Copiktra 2025 PA Fax 2755-A v1 01-01-25

Cosentyx 2025 PA Fax 1237-A v2 01-01-25

Cotellic 2025 PA Fax 1307-A v1 01-01-25

Cystagon 2025 PA Fax 803-A v1 01-01-25

Cysteamine Ophth 2025 PA Fax 926-A v1 01-01-25

D

Daraprim 2025 PA Fax 1395-A v1 01-01-25

Daurismo 2025 PA Fax 2794-A v1 01-01-25

Deferasirox 2025 PA Fax 553-A v1 01-01-25

Demser 2025 PA Fax 2531-A v1 01-01-25

Dexmethylphenidate 2025 PA Fax 4336-A v1 01-01-25

DHE Nasal 2025 PA Fax 2895-A v1 01-01-25

Diacomit 2025 PA Fax 2779-A v1 01-01-25

Doptelet 2025 PA Fax 2586-A v2 01-01-25

Drizalma Sprinkle 2025 PA Fax 3399-A v1 01-01-25

Dupixent 2025 PA Fax 1691-A v4 01-01-25

E

Elidel 2025 PA Fax 1399-A v1 01-01-25

Eligard 2025 PA Fax 5263-A v1 01-01-25

Emend Varubi 2025 PA Fax BD-3 v1 01-01-25

Emgality 2025 PA Fax 3111-A v1 01-01-25

Emsam 2025 PA Fax 1401-A v1 01-01-25

Endari 2025 PA Fax 2211-A v1 01-01-25

Epclusa 2025 PA Fax 1508-A v1 01-01-25

Epidiolex 2025 PA Fax 2608-A v1 01-01-25

Epoetin 2025 PA Fax 81-A v1 01-01-25

Eprontia 2025 PA Fax 5286-A v3 01-01-25

Ergotamine 2025 PA Fax 4607-A v1 01-01-25

Erivedge 2025 PA Fax 762-A v1 01-01-25

Erleada 2025 PA Fax 2499-A v1 01-01-25

Esbriet 2025 PA Fax 1217-A v1 01-01-25

Etanercept 2025 PA Fax 6570-A v1 01-01-25

Everolimus 2025 PA Fax 415-A v3 01-01-25

F

Fabrazyme 2025 PA Fax 576-A v1 01-01-25

Fanapt 2025 PA Fax 4533-A v2 01-01-25

Fasenra 2025 PA Fax 2414-A v2 01-01-25

Fentanyl Patch 2025 PA Fax 1398-A v1 01-01-25

Fetzima 2025 PA Fax 1404-A v1 01-01-25

Fintepla 2025 PA Fax 3983-A v1 01-01-25

Firmagon 2025 PA Fax 3873-A v1 01-01-25

Fotivda 2025 PA Fax 4620-A v2 01-01-25

Fruzaqla 2025 PA Fax 6255-A v1 01-01-25

Fycompa 2025 PA Fax 4557-A v1 01-01-25

G

Gattex 2025 PA Fax 938-A v1 01-01-25

Gavreto 2025 PA Fax 4207-A v1 01-01-25

Gilenya 2025 PA Fax 620-A v1 01-01-25

Gilotrif 2025 PA Fax 1011-A v2 01-01-25

Glatiramer 2025 PA Fax 544-A v1 01-01-25

Gleevec 2025 PA Fax 99-A v1 01-01-25

Gralise 2025 PA Fax 2535-A v1 01-01-25

Growth Hormone 2025 PA Fax 101-A v1 01-01-25

H

Harvoni 2025 PA Fax 1209-A v1 01-01-25

Hepatitis B 2025 PA Fax BD-5 v2 01-01-25

Herceptin Hylecta BDC 2025 PA Fax 2945-A v1 01-01-25

Hetlioz 2025 PA Fax 1125-A v2 01-01-25

HRM Anticonvulsants 2025 PA Fax 1410-B v2 01-01-25

HRM Antiparkinson 2025 PA Fax 1416-B v2 01-01-25

HRM Cyproheptadines 2025 PA Fax 3513-B v2 01-01-25

HRM Guanfacine ER 2025 PA Fax 3520-B v2 01-01-25

HRM Guanfacine IR 2025 PA Fax 3519-B v2 01-01-25

HRM Hydroxyzine Inj 2025 PA Fax 1415-B v2 01-01-25

HRM Hydroxyzine Oral 2025 PA Fax 1414-B v2 01-01-25

HRM Hypnotics 2025 PA Fax 1421-B v2 01-01-25

HRM Low Impact 2025 PA Fax 1422-B v2 01-01-25

HRM Muscle Relaxants PA Plus 2025 PA Fax 1420-B v2 01-01-25

HRM Promethazine 2025 PA Fax 1413-B v2 01-01-25

HRM Scopolamine 2025 PA Fax 3510-B v2 01-01-25

I

Ibrance 2025 PA Fax 1236-A v2 01-01-25

Icatibant 2025 PA Fax 809-A v1 01-01-25

Iclusig 2025 PA Fax 920-A v4 01-01-25

Idhifa 2025 PA Fax 2239-A v1 01-01-25

Imbruvica 2025 PA Fax 1050-A v2 01-01-25

Impavido 2025 PA Fax 3705-A v1 01-01-25

Inbrija 2025 PA Fax 2861-A v1 01-01-25

Increlex 2025 PA Fax 551-A v1 01-01-25

Infliximab 2025 PA Fax 187-A v1 01-01-25

Infusion 2025 PA Fax BD-20 v1 01-01-25

Inlyta 2025 PA Fax 747-A v1 01-01-25

Inqovi 2025 PA Fax 4008-A v1 01-01-25

Inrebic 2025 PA Fax 3162-A v1 01-01-25

Insulin Inj Supplies 2025 PA Fax 6434-A v1 01-01-25

Interferon 2025 PA Fax 543-A v1 01-01-25

Iressa 2025 PA Fax 1282-A v1 01-01-25

Isotretinoins 2025 PA Fax 1430-A v1 01-01-25

Iwilfin 2025 PA Fax 6306-A v1 01-01-25

J

Jakafi 2025 PA Fax 723-A v2 01-01-25

Jaypirca 2025 PA Fax 5769-A v4 01-01-25

Jynneos 2025 PA Fax BD-25 v1 01-01-25

K

Kalydeco 2025 PA Fax 753-A v1 01-01-25

Kesimpta 2025 PA Fax 4122-A v1 01-01-25

Ketoconazole PO 2025 PA Fax 1440-A v1 01-01-25

Keytruda 2025 PA Fax 1185-A v3 01-01-25

Kisqali-Kisqali Femara 2025 PA Fax 1638-A v1 01-01-25

Korlym 2025 PA Fax 778-A v1 01-01-25

Koselugo 2025 PA Fax 3771-A v2 01-01-25

Krazati 2025 PA Fax 5702-A v3 01-01-25

L

Lazcluze 2025 PA Fax 6622-A v1 01-01-25

Lenvima 2025 PA Fax 1248-A v1 01-01-25

Leuprolide Inj 2025 PA Fax 4629-A v2 01-01-25

Lidocaine Patch 2025 PA Fax 1433-A v3 01-01-25

Lidocaine Topical 2025 PA Fax 1434-A v1 01-01-25

Livtencity 2025 PA Fax 5092-A v1 01-01-25

Lonsurf 2025 PA Fax 1298-A v1 01-01-25

Lorbrena 2025 PA Fax 2788-A v2 01-01-25

Lotronex 2025 PA Fax 1435-A v1 01-01-25

Lovaza 2025 PA Fax 2480-A v1 01-01-25

Lumakras 2025 PA Fax 4762-A v1 01-01-25

Lumizyme 2025 PA Fax 593-A v1 01-01-25

Lupron Endometriosis 2025 PA Fax 567-A v1 01-01-25

Lupron PED 2025 PA Fax 549-A v1 01-01-25

Lynparza 2025 PA Fax 1232-A v2 01-01-25

Lyrica 2025 PA Fax 2898-A v1 01-01-25

Lytgobi 2025 PA Fax 5648-A v1 01-01-25

M

Mavyret 2025 PA Fax 2243-A v1 01-01-25

Megestrol 2025 PA Fax 1437-A v1 01-01-25

Mekinist 2025 PA Fax 999-A v1 01-01-25

Mektovi 2025 PA Fax 2613-A v1 01-01-25

Mepron 2025 PA Fax 3620-A v2 01-01-25

Methylphenidate 2025 PA Fax 3642-A v2 01-01-25

Methyltestosterone 2025 PA Fax 3707-A v1 01-01-25

Monjuvi 2025 PA Fax 4057-A v2 01-01-25

Mounjaro 2025 PA Fax 6085-A v1 01-01-25

N

Naglazyme 2025 PA Fax 577-A v1 01-01-25

Namenda 2025 PA Fax 1439-B v1 01-01-25

Nebs-Asthma COPD 2025 PA Fax BD-8 v1 01-01-25

Nebs-Mucolytics 2025 PA Fax BD-10 v1 01-01-25

Nebs-Pentamidine 2025 PA Fax BD-11 v1 01-01-25

Nerlynx 2025 PA Fax 2180-A v1 01-01-25

Nexavar 2025 PA Fax 417-A v2 01-01-25

Ninlaro 2025 PA Fax 1312-A v1 01-01-25

Nitisinone 2025 PA Fax 579-A v1 01-01-25

Northera 2025 PA Fax 1142-A v1 01-01-25

Noxafil Sus 2025 PA Fax 4505-A v1 01-01-25

Noxafil Tab 2025 PA Fax 4504-A v1 01-01-25

Nubeqa 2025 PA Fax 3149-A v2 01-01-25

Nuedexta 2025 PA Fax 1441-A v1 01-01-25

Nulojix 2025 PA Fax BD-26 v1 01-01-25

Nuplazid 2025 PA Fax 1366-A v1 01-01-25

Nurtec ODT 2025 PA Fax 4556-A v1 01-01-25

Nuvigil 2025 PA Fax 1442-A v2 01-01-25

O

Octreotide 2025 PA Fax 4361-A v1 01-01-25

Odomzo 2025 PA Fax 1283-A v1 01-01-25

Ofev 2025 PA Fax 1216-A v1 01-01-25

Ogsiveo 2025 PA Fax 6264-A v1 01-01-25

Ojemda 2025 PA Fax 6488-A v1 01-01-25

Ojjaara 2025 PA Fax 6190-A v3 01-01-25

Omnipod 2025 PA Fax 3573-A v3 01-01-25

Omnipod Go 2025 PA Fax 6504-A v1 01-01-25

Onureg 2025 PA Fax 4196-A v1 01-01-25

Opioids ER 2025 PA Fax 2493-A v1 01-01-25

Opsumit 2025 PA Fax 1049-A v1 01-01-25

Oral Chemo 2025 PA Fax BD-17 v1 01-01-25

Oral Intranasal Fentanyl 2025 PA Fax 1445-A v1 01-01-25

Orgovyx 2025 PA Fax 4413-A v1 01-01-25

Orkambi 2025 PA Fax 1279-A v1 01-01-25

Orserdu 2025 PA Fax 5776-A v1 01-01-25

Ozempic 2025 PA Fax 6080-A v1 01-01-25

P

Panretin 2025 PA Fax 4861-A v1 01-01-25

Parenteral Nutrition 2025 PA Fax BD-18 v1 01-01-25

Paxil Sus 2025 PA Fax 4617-A v1 01-01-25

Pegasys 2025 PA Fax 556-A v2 01-01-25

Pegfilgrastim 2025 PA Fax 153-A v2 01-01-25

Pemazyre 2025 PA Fax 3823-A v1 01-01-25

Phenylbutyrate 2025 PA Fax 965-A v1 01-01-25

Phesgo 2025 PA Fax 3987-A v1 01-01-25

Piqray 2025 PA Fax 3090-A v1 01-01-25

Pomalyst 2025 PA Fax 963-A v1 01-01-25

Prescriber Services 2025 PA Fax BD-13 v1 01-01-25

Prevymis 2025 PA Fax 4788-A v1 01-01-25

Protopic 2025 PA Fax 1449-A v1 01-01-25

Provigil 2025 PA Fax 1450-A v2 01-01-25

Pulmozyme BDC 2025 PA Fax 563-A v1 01-01-25

Q

Qinlock 2025 PA Fax 3902-A v1 01-01-25

Qualaquin 2025 PA Fax 1451-A v1 01-01-25

Qulipta 2025 PA Fax 5001-A v1 01-01-25

R

Rabies Vaccine 2025 PA Fax BD-23 v1 01-01-25

Regranex 2025 PA Fax 1453-A v1 01-01-25

Relistor Inj 2025 PA Fax 1454-A v1 01-01-25

Renflexis 2025 PA Fax 3947-A v1 01-01-25

Repatha 2025 PA Fax 1774-A v1 01-01-25

Retevmo 2025 PA Fax 3875-A v1 01-01-25

Revlimid 2025 PA Fax 386-A v1 01-01-25

Rezlidhia 2025 PA Fax 5684-A v1 01-01-25

Rezurock 2025 PA Fax 4854-A v1 01-01-25

Rinvoq 2025 PA Fax 3186-A v5 01-01-25

Rozlytrek 2025 PA Fax 3166-A v2 01-01-25

Rubraca 2025 PA Fax 1569-A v1 01-01-25

Rybelsus 2025 PA Fax 6081-A v1 01-01-25

Rydapt 2025 PA Fax 1818-A v1 01-01-25

S

Sapropterin 2025 PA Fax 341-A v1 01-01-25

Scemblix 2025 PA Fax 5048-A v2 01-01-25

Seroquel XR 2025 PA Fax 2875-A v2 01-01-25

Signifor 2025 PA Fax 970-A v1 01-01-25

Sildenafil PO 2025 PA Fax 641-A v1 01-01-25

Sirturo 2025 PA Fax 1456-A v2 01-01-25

Skyrizi 2025 PA Fax 3048-A v3 01-01-25

Somatuline Depot 2025 PA Fax 671-A v1 01-01-25

Somavert 2025 PA Fax 564-A v1 01-01-25

Sotyktu 2025 PA Fax 5622-A v2 01-01-25

Sporanox Capsules 2025 PA Fax 1432-A v1 01-01-25

Sprycel 2025 PA Fax 422-A v1 01-01-25

Stelara 2025 PA Fax 560-A v2 01-01-25

Stivarga 2025 PA Fax 820-A v2 01-01-25

Stromectol Tab 2025 PA Fax 4922-A v1 01-01-25

Sutent 2025 PA Fax 418-A v1 01-01-25

Symdeko 2025 PA Fax 2515-A v1 01-01-25

Synarel 2025 PA Fax 5802-A v2 01-01-25

Syprine 2025 PA Fax 2486-A v1 01-01-25

T

Tabrecta 2025 PA Fax 3879-A v1 01-01-25

Tadalafil 2025 PA Fax 639-A v1 01-01-25

Tadalafil BPH 2025 PA Fax 6552-A v1 01-01-25

Tafinlar 2025 PA Fax 1000-A v1 01-01-25

Tagrisso 2025 PA Fax 1305-A v2 01-01-25

Talzenna 2025 PA Fax 2781-A v2 01-01-25

Tarceva 2025 PA Fax 223-A v1 01-01-25

Targretin caps 2025 PA Fax 507-A v1 01-01-25

Targretin Gel 2025 PA Fax 4618-A v1 01-01-25

Tasigna 2025 PA Fax 421-A v2 01-01-25

Tavneos 2025 PA Fax 5032-A v1 01-01-25

Tazorac 2025 PA Fax 1462-A v1 01-01-25

Tazverik 2025 PA Fax 3503-A v1 01-01-25

Tecentriq 2025 PA Fax 1374-A v2 01-01-25

Temazepam 2025 PA Fax 3501-B v2 01-01-25

Tepmetko 2025 PA Fax 4496-A v1 01-01-25

Terbinafine 2025 PA Fax 6413-A v1 01-01-25

Teriparatide 2025 PA Fax 94-A v1 01-01-25

Testosterone Cypionate 2025 PA Fax 1464-A v1 01-01-25

Testosterone Enanthate 2025 PA Fax 1463-A v1 01-01-25

Testosterone Topical 2025 PA Fax 1465-A v1 01-01-25

Tetanus Vaccine 2025 PA Fax BD-19 v1 01-01-25

Thalomid 2025 PA Fax 230-A v1 01-01-25

Tibsovo 2025 PA Fax 2637-A v1 01-01-25

Tobi Podhaler 2025 PA Fax 1507-A v1 01-01-25

Tobramycin BDC 2025 PA Fax 232-A v1 01-01-25

Toremifene 2025 PA Fax 3628-A v1 01-01-25

Tracleer 2025 PA Fax 234-A v2 01-01-25

Tranxene T 2025 PA Fax 1466-B v2 01-01-25

Trastuzumab BDC 2025 PA Fax 1499-A v2 01-01-25

Trazimera BDC 2025 PA Fax 3945-A v1 01-01-25

Tremfya 2025 PA Fax 2157-A v3 01-01-25

Treprostinil BDC 2025 PA Fax 188-A v1 01-01-25

Tretinoins Topical 2025 PA Fax 1467-A v1 01-01-25

Trikafta 2025 PA Fax 3375-A v1 01-01-25

Trintellix 2025 PA Fax 1468-A v2 01-01-25

Trulicity 2025 PA Fax 6082-A v1 01-01-25

Truqap 2025 PA Fax 6266-A v1 01-01-25

Truxima 2025 PA Fax 4710-A v1 01-01-25

Tukysa 2025 PA Fax 3781-A v2 01-01-25

Turalio 2025 PA Fax 3152-A v1 01-01-25

Tyenne 2025 PA Fax 6436-A v1 01-01-25

Tykerb 2025 PA Fax 308-A v1 01-01-25

U

Ubrelvy 2025 PA Fax 3485-A v1 01-01-25

Uceris 2025 PA Fax 4500-A v1 01-01-25

Uloric 2025 PA Fax 2885-A v1 01-01-25

V

Valchlor 2025 PA Fax 1044-A v1 01-01-25

Valium 2025 PA Fax 5774-B v2 01-01-25

Vanflyta 2025 PA Fax 6087-A v2 01-01-25

Velcade BDC 2025 PA Fax 763-A v1 01-01-25

Velsipity 2025 PA Fax 6280-A v2 01-01-25

Venclexta 2025 PA Fax 1353-A v1 01-01-25

Veozah 2025 PA Fax 6004-A v1 01-01-25

Verquvo 2025 PA Fax 4436-A v1 01-01-25

Versacloz 2025 PA Fax 4553-A v1 01-01-25

Verzenio 2025 PA Fax 2343-A v1 01-01-25

Vfend 2025 PA Fax 2877-A v1 01-01-25

Vigabatrin 2025 PA Fax 548-A v2 01-01-25

Vigafyde 2025 PA Fax 6546-A v1 01-01-25

Vitamin D Topical 2025 PA Fax 2569-A v1 01-01-25

Vitrakvi 2025 PA Fax 2801-A v1 01-01-25

Vizimpro 2025 PA Fax 2771-A v1 01-01-25

Vonjo 2025 PA Fax 5264-A v1 01-01-25

Voranigo 2025 PA Fax 6590-A v1 01-01-25

Vosevi 2025 PA Fax 2177-A v1 01-01-25

Votrient 2025 PA Fax 547-A v1 01-01-25

Vowst 2025 PA Fax 5993-A v2 01-01-25

Vyvanse 2025 PA Fax 3674-A v1 01-01-25

W

Welireg 2025 PA Fax 4902-A v3 01-01-25

X

Xalkori 2025 PA Fax 697-A v2 01-01-25

Xdemvy 2025 PA Fax 6111-A v2 01-01-25

Xeljanz 2025 PA Fax 914-A v3 01-01-25

Xenazine 2025 PA Fax 360-A v2 01-01-25

Xermelo 2025 PA Fax 1671-A v1 01-01-25

Xgeva BDC 2025 PA Fax 637-A v1 01-01-25

Xhance 2025 PA Fax 4539-A v3 01-01-25

Xifaxan 550mg 2025 PA Fax 1480-A v2 01-01-25

Xolair 2025 PA Fax 473-A v2 01-01-25

Xospata 2025 PA Fax 2808-A v1 01-01-25

Xpovio 2025 PA Fax 3121-A v1 01-01-25

Xtandi 2025 PA Fax 816-A v2 01-01-25

Xyrem 2025 PA Fax 1481-A v2 01-01-25

Y

There are no drugs beginning with the letter Y that require prior authorization at this time.

Z

Zarxio 2025 PA Fax 4507-A v1 01-01-25

Zejula 2025 PA Fax 1689-A v1 01-01-25

Zelboraf 2025 PA Fax 696-A v1 01-01-25

Zirabev BDC 2025 PA Fax 3944-A v3 01-01-25

Zolinza 2025 PA Fax 566-A v1 01-01-25

Zonisade 2025 PA Fax 5624-A v1 01-01-25

Ztalmy 2025 PA Fax 5338-A v1 01-01-25

Zurzuvae 2025 PA Fax 6282-A v1 01-01-25

Zydelig 2025 PA Fax 1174-A v1 01-01-25

Zykadia 2025 PA Fax 1136-A v2 01-01-25

Zyprexa Relprevv 2025 PA Fax 1483-A v1 01-01-25

Zytiga 2025 PA Fax 661-A v1 01-01-25

This page was last updated 01/03/2025