Sample Notes Page - CareFirst BlueCross BlueShield
Prescription Drug Detail

Brand Name
Brand Tier
Generic Name
Generic Tier
H.P. Acthar Gel
 
(Tier 3)
 
Not
Available
Not
Available

Prior Authorization Required: Yes
Quantity Limit: No
Category: Hormones\miscellaneous
Maintenance Drug: No
Notes: This prior authorization is only applicable to H.P. Acthar gel that is being self-administered.
Attachments: Acthar.pdf