Sample Notes Page - CareFirst BlueCross BlueShield
Prescription Drug Detail

Brand Name
Brand Tier
Generic Name
Generic Tier
ENBREL
 
(Tier 2)
 
Not
Available
Not
Available

Prior Authorization Required: Yes
Quantity Limit: No
Category: Diseases\Arthritis (rheumatoid)
Maintenance Drug: No
Notes: This medication requires Prior Authorization. Please have your physician call 1-866-522-2486 before prescribing this medication. Members who have a 4th tier benefit for self-administered injectables can find the copay level in their benefit contract.
Attachments: Psoriasis PA FINAL.pdfArthritis PA Form.pdf