Prior Authorization for Prescription Drugs - CareFirst BlueCross BlueShield

Prior Authorization

Some prescriptions require advance approval before you can get them. Your physician must call 1-800-314-2872 before prescribing the following medications. Members can call Argus Health Systems, Inc. (Argus) at 1-800-241-3371 with any questions about prior authorization.

*Please note that prior authorization forms are for provider use only.

Brand Name	Generic Name	Prior Authorization Form*
ACIPHEX (Tier 3)	Generic Not Available	View Form
ACTIQ (Tier 3)	fentanyl lozenge (Tier 1)	View Form
AFINITOR (Tier 2)	Generic Not Available	View Form
Aplenzin (Tier 3)	Generic Not Available	View Form
ARANESP (Tier 3)	Generic Not Available	View Form
AVINZA (Tier 3)	Generic Not Available	View Form
AVITA (Tier 3)	Generic Not Available	View Form
AVONEX (Tier 3)	Generic Not Available	View Form
BETASERON (Tier 3)	Generic Not Available	View Form
BRAVELLE (Tier 2)	Generic Not Available	View Form
BYETTA (Tier 2)	Generic Not Available	View Form
CELEBREX (Tier 3)	Generic Not Available	View Form
CESAMET (Tier 3)	Generic Not Available	View Form
CETROTIDE (Tier 2)	Generic Not Available	View Form
Cimzia prefilled syringe (Tier 3)	Generic Not Available	View Form View Form
COPAXONE (Tier 2)	Generic Not Available	View Form
DAYTRANA (Tier 3)	Generic Not Available	View Form
DIFFERIN (Tier 3)	Generic Not Available	View Form
ENBREL (Tier 2)	Generic Not Available	View Form View Form
EPIDUO (Tier 3)	Generic Not Available	View Form
EPOGEN (Tier 3)	Generic Not Available	View Form
EXTAVIA (Tier 3)	Generic Not Available	View Form
FENTORA (Tier 3)	Generic Not Available	View Form
FLECTOR Patch (Tier 3)	Generic Not Available	View Form
FOLLISTIM AQ (Tier 3)	Generic Not Available	View Form
FORTEO (Tier 3)	Generic Not Available	View Form
GENOTROPIN (Tier 3)	Generic Not Available	View Form View Form
GLEEVEC (Tier 2)	Generic Not Available	View Form
GONAL-F (Tier 2)	Generic Not Available	View Form
HUMATROPE (Tier 3)	Generic Not Available	View Form View Form
HUMIRA (Tier 2)	Generic Not Available	View Form View Form View Form
HYCAMTIN (Tier 2)	Generic Not Available	View Form
INCRELEX (Tier 3)	Generic Not Available	View Form
KADIAN (Tier 3)	Generic Not Available	View Form
KINERET (Tier 3)	Generic Not Available	View Form
LEUKINE (Tier 3)	Generic Not Available	View Form
LOVAZA (Tier 3)	Generic Not Available	View Form
LUVERIS (Tier 3)	Generic Not Available	View Form
MENOPUR (Tier 2)	Generic Not Available	View Form
NEULASTA (Tier 3)	Generic Not Available	View Form
NEUMEGA (Tier 3)	Generic Not Available	View Form
NEUPOGEN (Tier 2)	Generic Not Available	View Form
NEXAVAR (Tier 2)	Generic Not Available	View Form
NEXIUM (Tier 3)	Generic Not Available	View Form
NORDITROPIN (Tier 2)	Generic Not Available	View Form View Form
NOVAREL (Tier 3)	chorionic gonadotropin (Tier 1)	View Form
NUTROPIN (Tier 3)	Generic Not Available	View Form View Form
NUVIGIL (Tier 3)	Generic Not Available	View Form
OMNITROPE (Tier 3)	Generic Not Available	View Form View Form
ONSOLIS (Tier 3)	Generic Not Available	View Form
OPANA/OPANA ER (Tier 3)	Generic Not Available	View Form
OVIDREL (Tier 2)	Generic Not Available	View Form
PEG-INTRON (Tier 3)	Generic Not Available	View Form
PEGASYS (Tier 2)	Generic Not Available	View Form
PREGNYL (Tier 3)	chorionic gonadotropin (Tier 1)	View Form
PRILOSEC 10mg & 40mg (Tier 3)	omeprazole 10mg & 40mg (Tier 1)	View Form
PRILOSEC 2.5mg & 10mg sol'n (Tier 3)	Generic Not Available	View Form
PROCRIT (Tier 2)	Generic Not Available	View Form
PROVIGIL (Tier 3)	Generic Not Available	View Form
REBIF (Tier 2)	Generic Not Available	View Form
REPRONEX (Tier 2)	Generic Not Available	View Form
RETIN-A CREAM and GEL (Tier 3)	tretinoin cream and gel (Tier 1)	View Form
RETIN-A LIQUID (Tier 3)	Generic Not Available	View Form
RETIN-A MICRO GEL (Tier 3)	Generic Not Available	View Form
REVLIMID (Tier 2)	Generic Not Available	View Form
SAIZEN (Tier 3)	Generic Not Available	View Form View Form
SEROSTIM (Tier 2)	Generic Not Available	View Form
SIMPONI (Tier 3)	Generic Not Available	View Form
SPRYCEL (Tier 2)	Generic Not Available	View Form
SUTENT (Tier 2)	Generic Not Available	View Form
SYMLIN (Tier 3)	Generic Not Available	View Form
TARCEVA (Tier 2)	Generic Not Available	View Form
TASIGNA (Tier 2)	Generic Not Available	View Form
TAZORAC (Tier 2)	Generic Not Available	View Form
TEMODAR (Tier 2)	Generic Not Available	View Form
TEV-TROPIN (Tier 3)	Generic Not Available	View Form View Form
THALOMID (Tier 2)	Generic Not Available	View Form
TRETIN-X (Tier 3)	Generic Not Available	View Form
TYKERB (Tier 2)	Generic Not Available	View Form
VOLTAREN gel (Tier 3)	Generic Not Available	View Form
VOTRIENT (Tier 2)	Generic Not Available	View Form
XELODA (Tier 2)	Generic Not Available	View Form
ZEGERID (Tier 3)	Generic Not Available	View Form
ZIANA (Tier 3)	Generic Not Available	View Form
ZOLINZA (Tier 2)	Generic Not Available	View Form
ZORBTIVE (Tier 3)	Generic Not Available	View Form
Brand Not Available	Generic Not Available	View Form
Brand Not Available	progesterone in oil (Tier 1)	View Form
Brand Not Available	ganirelix acetate (Tier 1)	View Form

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This list is subject to your benefit plan and may change periodically.

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