• Print:
  • Text Size:

Prescription Drug Database

Step Therapy/Prior Authorization

Step Therapy/Prior Authorization encourages doctors to prescribe therapies in a certain order, based on clinical guidance and cost effectiveness. Your provider must call CareFirst's Pharmacy Services at 800-241-3371 before prescribing the following medications. If you have questions about prior authorization, give us a call at 800-241-3371.

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


Brand Name
Generic Name
Prior Authorization Form
Brand Name (Tier 3): ABSTRAL Generic Not AvailableCUT0355 Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys.pdf
Brand Name (Tier 3): ACCU-CHEK meter test strips Generic Not AvailableCUT0360 Diabetic Test Strips.pdf
Brand Name (Tier 3): ACIPHEX Generic Not AvailableCUT0369 PPI.pdf
Brand Name (Tier 3): ACTEMRA Generic Not AvailableCUT0249 Arthritis.pdf
Brand Name (Tier 3): ACTIQGeneric Name (Tier 1): fentanyl lozengeCUT0355 Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys.pdf
Brand Name (Tier 3): ADCIRCA Generic Not AvailableCUT0357 Adcirca.pdf
Brand Name (Tier 2): AFINITOR Generic Not AvailableCUT0385 Afinitor.pdf
Brand Name (Tier 3): AMPYRA Generic Not AvailableCUT0358 Ampyra.pdf
Brand Name (Tier 3): ARANESP Generic Not AvailableCUT0390 Erythropoetins Form.pdf
Brand Name (Tier 3): ATRALIN Generic Not AvailableCUT0374 Topical Retinoids.pdf
Brand Name (Tier 3): AUBAGIO Generic Not AvailableCUT0384 MS Drugs.pdf
Brand Name (Tier 3): AVITA Generic Not AvailableCUT0374 Topical Retinoids.pdf
Brand Name (Tier 3): AVONEX Generic Not AvailableCUT0384 MS Drugs.pdf
Brand Name (Tier 3): BETASERON Generic Not AvailableCUT0384 MS Drugs.pdf
Brand Name (Tier 2): BOSULIF Generic Not AvailableCUT0386 Bosulif.pdf
Brand Name (Tier 2): BRAVELLE Generic Not AvailableCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 2): CAPRELSA Generic Not AvailableCUT0387 Caprelsa.pdf
Brand Name (Tier 2): CETROTIDE Generic Not AvailableCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 3): CIMZIA prefilled syringe Generic Not AvailableCUT0249 Arthritis.pdf
CUT0250 Crohn Disease.pdf
Brand Name (Tier 2): COMETRIQ Generic Not AvailableCUT0388 Cometriq.pdf
Brand Name (Tier 3): Contour Next Strips Generic Not AvailableCUT0360 Diabetic Test Strips.pdf
Brand Name (Tier 2): COPAXONE Generic Not AvailableCUT0384 MS Drugs.pdf
Brand Name (Tier 3): Diabetic Test Strips Generic Not AvailableCUT0360 Diabetic Test Strips.pdf
Brand Name (Tier 3): DIFFERINGeneric Name (Tier 1): adapaleneCUT0374 Topical Retinoids.pdf
Brand Name (Tier 3): EGRIFTA Generic Not AvailableCUT0361 Egrifta.pdf
Brand Name (Tier 2): ENBREL Generic Not AvailableCUT0248 Psoriasis.pdf
CUT0249 Arthritis.pdf
Brand Name (Tier 3): EPIDUO Generic Not AvailableCUT0374 Topical Retinoids.pdf
Brand Name (Tier 3): EPOGEN Generic Not AvailableCUT0390 Erythropoetins Form.pdf
Brand Name (Tier 2): ERIVEDGE Generic Not AvailableCUT0389 Erivedge.pdf
Brand Name (Tier 3): EXTAVIA Generic Not AvailableCUT0384 MS Drugs.pdf
Brand Name (Tier 3): FENTORA Generic Not AvailableCUT0355 Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys.pdf
Brand Name (Tier 3): FOLLISTIM AQ Generic Not AvailableCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 3): FreeStyle test strips Generic Not AvailableCUT0360 Diabetic Test Strips.pdf
Brand Name (Tier 3): GATTEX Generic Not AvailableCUT0362 Gattex.pdf
Brand Name (Tier 3): GENOTROPIN Generic Not AvailableCUT0380 Growth Hormone - Adult.pdf
CUT0381 Growth Hormone - Children.pdf
Brand Name (Tier 3): GILENYA Generic Not AvailableCUT0384 MS Drugs.pdf
Brand Name (Tier 2): GILOTRIF Generic Not AvailableGILOTRIF_Form.pdf
Brand Name (Tier 2): GLEEVEC Generic Not AvailableCUT0391 Gleevec.pdf
Brand Name (Tier 2): GONAL-F Generic Not AvailableCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 3): HUMATROPE Generic Not AvailableCUT0380 Growth Hormone - Adult.pdf
CUT0381 Growth Hormone - Children.pdf
Brand Name (Tier 2): HUMIRA Generic Not AvailableCUT0250 Crohn Disease.pdf
CUT0414 Ulcerative Colitis.pdf
CUT0249 Arthritis.pdf
CUT0248 Psoriasis.pdf
Brand Name (Tier 2): HYCAMTIN Generic Not AvailableCUT0392 Hycamtin.pdf
Brand Name (Tier 3): H.P. Acthar Gel Generic Not AvailableCUT0356 Acthar.pdf
Brand Name (Tier 2): IMBRUVICA Generic Not AvailableCUT0505 Imbruvica.pdf
Brand Name (Tier 3): INCIVEK Generic Not AvailableCUT0383 HCV Triple.pdf
Brand Name (Tier 3): INCRELEX Generic Not AvailableCUT0364 Increlex.pdf
Brand Name (Tier 2): INLYTA Generic Not AvailableCUT0394 Inlyta.pdf
Brand Name (Tier 2): JAKAFI Generic Not AvailableCUT0395 Jakafi.pdf
Brand Name (Tier 3): KALYDECO Generic Not AvailableCUT0396 Kalydeco.pdf
Brand Name (Tier 3): KINERET Generic Not AvailableCUT0249 Arthritis.pdf
Brand Name (Tier 3): LANTUS Generic Not AvailableCUT0365 Lantus.pdf
Brand Name (Tier 3): LAZANDA Generic Not AvailableCUT0355 Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys.pdf
Brand Name (Tier 3): LEUKINE Generic Not AvailableCUT0397 Leukine.pdf
Brand Name (Tier 3): LOVAZA Generic Not AvailableCUT0366 Lovaza.pdf
Brand Name (Tier 2): MEKINIST Generic Not AvailableCUT0398 Menkinist Tafinlar Zelboraf.pdf
Brand Name (Tier 2): MENOPUR Generic Not AvailableCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 3): NEULASTA Generic Not AvailableCUT0400 Neupogen, Neulasta.pdf
Brand Name (Tier 3): NEUMEGA Generic Not AvailableCUT0399 Neumega.pdf
Brand Name (Tier 2): NEUPOGEN Generic Not AvailableCUT0400 Neupogen, Neulasta.pdf
Brand Name (Tier 2): NEXAVAR Generic Not AvailableCUT0401 Nexavar.pdf
Brand Name (Tier 3): NEXIUM Generic Not AvailableCUT0369 PPI.pdf
Brand Name (Tier 2): NORDITROPIN Generic Not AvailableCUT0380 Growth Hormone - Adult.pdf
CUT0381 Growth Hormone - Children.pdf
Brand Name (Tier 3): NOVARELGeneric Name (Tier 1): chorionic gonadotropinCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 3): NUTROPIN Generic Not AvailableCUT0380 Growth Hormone - Adult.pdf
CUT0381 Growth Hormone - Children.pdf
Brand Name (Tier 3): NUVIGIL Generic Not AvailableCUT0370 Provigil, Nuvigil.pdf
Brand Name (Tier 3): OLYSIO Generic Not AvailableCUT0500 Hepatitis C Olysio.pdf
Brand Name (Tier 3): OMNITROPE Generic Not AvailableCUT0380 Growth Hormone - Adult.pdf
CUT0381 Growth Hormone - Children.pdf
Brand Name (Tier 3): ONSOLIS Generic Not AvailableCUT0355 Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys.pdf
Brand Name (Tier 3): ORENCIA Generic Not AvailableCUT0249 Arthritis.pdf
Brand Name (Tier 3): OVIDREL Generic Not AvailableCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 3): PEG-INTRON Generic Not AvailableCUT0382 HCV Standard.pdf
CUT0383 HCV Triple.pdf
Brand Name (Tier 2): PEGASYS Generic Not AvailableCUT0382 HCV Standard.pdf
CUT0383 HCV Triple.pdf
Brand Name (Tier 3): PENNSAID Generic Not Available 
Brand Name (Tier 2): POMALYST Generic Not AvailableCUT0402 Pomalyst.pdf
Brand Name (Tier 3): PREGNYLGeneric Name (Tier 1): chorionic gonadotropinCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 2): PROCRIT Generic Not AvailableCUT0390 Erythropoetins Form.pdf
Brand Name (Tier 3): PROVIGILGeneric Name (Tier 1): modafinilCUT0370 Provigil, Nuvigil.pdf
Brand Name (Tier 2): REBIF Generic Not AvailableCUT0384 MS Drugs.pdf
Brand Name (Tier 2): REPRONEX Generic Not AvailableCUT9047 Infertility Therapy Enrollment.pdf
Brand Name (Tier 3): RETIN-A CREAM and GELGeneric Name (Tier 1): tretinoin cream and gelCUT0374 Topical Retinoids.pdf
Brand Name (Tier 3): RETIN-A MICRO GELGeneric Name (Tier 1): tretinoinCUT0374 Topical Retinoids.pdf
Brand Name (Tier 2): REVLIMID Generic Not AvailableCUT0403 Revlimid.pdf
Brand Name (Tier 3): SAIZEN Generic Not AvailableCUT0380 Growth Hormone - Adult.pdf
CUT0381 Growth Hormone - Children.pdf
Brand Name (Tier 2): SEROSTIM Generic Not AvailableCUT0372 Serostim.pdf
Brand Name (Tier 3): SIGNIFOR Generic Not AvailableCUT0404 Signifor.pdf
Brand Name (Tier 3): SIMPONI Generic Not AvailableCUT0414 Ulcerative Colitis.pdf
CUT0249 Arthritis.pdf
Brand Name (Tier 3): SOLODYN Generic Not AvailableCUT0373 Solodyn.pdf
Brand Name (Tier 3): SOVALDI Generic Not AvailableCUT0501 Hepatitis C Sovaldi.pdf
Brand Name (Tier 2): SPRYCEL Generic Not AvailableCUT0405 Sprycel.pdf
Brand Name (Tier 3): STELARA Generic Not AvailableCUT0248 Psoriasis.pdf
Brand Name (Tier 2): STIVARGA Generic Not AvailableCUT0406 Stivarga.pdf
Brand Name (Tier 3): SUBSYS Generic Not AvailableCUT0355 Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys.pdf
Brand Name (Tier 2): SureStep Generic Not AvailableCUT0360 Diabetic Test Strips.pdf
Brand Name (Tier 2): SUTENT Generic Not AvailableCUT0407 Sutent.pdf
Brand Name (Tier 2): SYLATRON Generic Not AvailableCUT0408 Sylatron.pdf
Brand Name (Tier 2): TAFINLAR Generic Not AvailableCUT0398 Menkinist Tafinlar Zelboraf.pdf
Brand Name (Tier 2): TARCEVA Generic Not AvailableCUT0409 Tarceva.pdf
Brand Name (Tier 2): TASIGNA Generic Not AvailableCUT0410 Tasigna.pdf
Brand Name (Tier 2): TAZORAC Generic Not AvailableCUT0374 Topical Retinoids.pdf
Brand Name (Tier 3): TECFIDERA Generic Not AvailableCUT0384 MS Drugs.pdf
Brand Name (Tier 3): TEMODARGeneric Name (Tier 1): temozolomideCUT0411 Temodar.pdf
Brand Name (Tier 3): TEV-TROPIN Generic Not AvailableCUT0380 Growth Hormone - Adult.pdf
CUT0381 Growth Hormone - Children.pdf
Brand Name (Tier 2): THALOMID Generic Not AvailableCUT0412 Thalomid.pdf
Brand Name (Tier 3): TRETIN-X Generic Not AvailableCUT0374 Topical Retinoids.pdf
Brand Name (Tier 2): TYKERB Generic Not AvailableCUT0413 Tykerb.pdf
Brand Name (Tier 3): VASCEPA Generic Not AvailableCUT0376 Vaspeca.pdf
Brand Name (Tier 3): VELTIN Generic Not AvailableCUT0374 Topical Retinoids.pdf
Brand Name (Tier 3): VICTRELIS Generic Not AvailableCUT0383 HCV Triple.pdf
Brand Name (Tier 3): VIMOVO Generic Not AvailableCUT0369 PPI.pdf
Brand Name (Tier 2): VOTRIENT Generic Not AvailableCUT0415 Votrient.pdf
Brand Name (Tier 2): XALKORI Generic Not AvailableCUT0416 Xalkori.pdf
Brand Name (Tier 3): XELJANZ Generic Not AvailableCUT0249 Arthritis.pdf
Brand Name (Tier 3): XELODAGeneric Name (Tier 1): capecitabineCUT0417 Xeloda.pdf
Brand Name (Tier 2): XTANDI Generic Not AvailableCUT0418 Xtandi.pdf
Brand Name (Tier 3): XYREM Generic Not AvailableCUT0378 Xyrem.pdf
Brand Name (Tier 3): ZEGERID PACKETS Generic Not AvailableCUT0369 PPI.pdf
Brand Name (Tier 2): ZELBORAF Generic Not AvailableCUT0398 Menkinist Tafinlar Zelboraf.pdf
Brand Name (Tier 3): ZIANAGeneric Name (Tier 1): clindamycin/tretinoinCUT0374 Topical Retinoids.pdf
Brand Name (Tier 2): ZOLINZA Generic Not AvailableCUT0420 Zolinza.pdf
Brand Name (Tier 3): ZORBTIVE Generic Not AvailableCUT0379 Zorbtive.pdf
Brand Name (Tier 2): ZYTIGA Generic Not AvailableCUT0421 Zytiga.pdf
Brand Not Available Generic Not AvailableCUT0249 Arthritis.pdf
Brand Not AvailableGeneric Name (Tier 1): buprenorphine tab 
Brand Not Available Generic Not Available 
Brand Not Available Generic Not AvailableCUT9047 Infertility Therapy Enrollment.pdf
Brand Not AvailableGeneric Name (Tier 1): ganirelix acetateCUT9047 Infertility Therapy Enrollment.pdf
Brand Not AvailableGeneric Name (Tier 1): progesterone in oilCUT9047 Infertility Therapy Enrollment.pdf