Prior Authorizations

Certain medications require a prior authorization to ensure that they are medically necessary and part of a specific treatment plan. Below are the prior authorization program guidelines:

The prescribing physician should notify ProCare Rx in advance about the medical condition that requires the use of drugs that appear on the prior authorization list; obtaining the authorization in advance will prevent delays at the pharmacy. ProCare Rx's staff is available at 1-800-662-0586 (8 AM to 8 PM, Monday through Friday) to provide immediate authorization. Once the drug is authorized, it can be filled at any participating pharmacy.

Physicians may fax prior authorization requests to 1-800-662-0590.

All Prior Authorizations have been approved by the ProCare Rx Pharmacy & Therapeutic Committee.

Filename Size
An Adobe Acrobat file ADD-ADHD.pdf 64.5 KB
An Adobe Acrobat file Abilify.pdf 73.72 KB
An Adobe Acrobat file Actiq - Fentora - Onsolis.pdf 71.61 KB
An Adobe Acrobat file Adempas.pdf 68.1 KB
An Adobe Acrobat file Alferon-N.pdf 70.01 KB
An Adobe Acrobat file Alprolix.pdf 75.64 KB
An Adobe Acrobat file Anti-Hemophilic Factor.pdf 70.28 KB
An Adobe Acrobat file Anticoagulants.pdf 70.78 KB
An Adobe Acrobat file Aptiom.pdf 74.64 KB
An Adobe Acrobat file Aranesp.pdf 72.39 KB
An Adobe Acrobat file Arava.pdf 78.42 KB
An Adobe Acrobat file Aubagio.pdf 67.99 KB
An Adobe Acrobat file Avonex, Rebif.pdf 80.92 KB
An Adobe Acrobat file Belviq.pdf 71.17 KB
An Adobe Acrobat file Betaseron.pdf 83.58 KB
An Adobe Acrobat file Bosulif.pdf 75.14 KB
An Adobe Acrobat file Brand Medically Necessary.pdf 76.36 KB
An Adobe Acrobat file Byetta.pdf 68.28 KB
An Adobe Acrobat file Celebrex.pdf 74.96 KB
An Adobe Acrobat file Cimzia.pdf 75.19 KB
An Adobe Acrobat file Cometriq.pdf 77.25 KB
An Adobe Acrobat file Copaxone.pdf 71 KB
An Adobe Acrobat file Copegus, Rebetol, Ribasphere, Ribapak, Virazole, Ribavirin.pdf 79.54 KB
An Adobe Acrobat file Cyramza.pdf 77.13 KB
An Adobe Acrobat file Cystaran.pdf 67.15 KB
An Adobe Acrobat file Cytoxan.pdf 69.06 KB
An Adobe Acrobat file Dexedrine Spansule.pdf 69.04 KB
An Adobe Acrobat file Egrifta.pdf 73.64 KB
An Adobe Acrobat file Elidel.pdf 68.76 KB
An Adobe Acrobat file Emend.pdf 68.13 KB
An Adobe Acrobat file Enbrel.pdf 71.51 KB
An Adobe Acrobat file Entyvio.pdf 77.85 KB
An Adobe Acrobat file Farxiga.pdf 68.01 KB
An Adobe Acrobat file Flolan.pdf 68.03 KB
An Adobe Acrobat file Forteo.pdf 78.64 KB
An Adobe Acrobat file Fuzeon.pdf 69.38 KB
An Adobe Acrobat file Gattex.pdf 80.44 KB
An Adobe Acrobat file General Prior Authorization.pdf 76.51 KB
An Adobe Acrobat file Gilotrif.pdf 74.36 KB
An Adobe Acrobat file Hemangeol.pdf 69.25 KB
An Adobe Acrobat file Hepatitis B Vaccine.pdf 64.93 KB
An Adobe Acrobat file Hepsera.pdf 74.28 KB
An Adobe Acrobat file Hetlioz.pdf 67.14 KB
An Adobe Acrobat file Human Growth Hormone for Adults.pdf 69.44 KB
An Adobe Acrobat file Human Growth Hormone for Children_Non-Preferred_.pdf 73.04 KB
An Adobe Acrobat file Human Growth Hormone for HIV Wasting in Adults.pdf 88.46 KB
An Adobe Acrobat file Humira.pdf 77.19 KB
An Adobe Acrobat file Iclusig.pdf 68.28 KB
An Adobe Acrobat file Immune Globulins.pdf 71.93 KB
An Adobe Acrobat file Immunosuppressive Agents.pdf 63.43 KB
An Adobe Acrobat file Increlex.pdf 81.84 KB
An Adobe Acrobat file Infertility Medications.pdf 70.12 KB
An Adobe Acrobat file Injectafer.pdf 68.14 KB
An Adobe Acrobat file Intron-A.pdf 73.15 KB
An Adobe Acrobat file Isotretinoin.pdf 80.64 KB
An Adobe Acrobat file Juxtapid.pdf 69.94 KB
An Adobe Acrobat file Kineret.pdf 77.75 KB
An Adobe Acrobat file Kynamro.pdf 69.09 KB
An Adobe Acrobat file Kyprolis.pdf 68.34 KB
An Adobe Acrobat file Lamisil.pdf 73.83 KB
An Adobe Acrobat file Lazanda.pdf 78.9 KB
An Adobe Acrobat file Lemtrada.pdf 90.04 KB
An Adobe Acrobat file Leukine.pdf 75.96 KB
An Adobe Acrobat file Liptruzet.pdf 72.41 KB
An Adobe Acrobat file Lotronex.pdf 76.47 KB
An Adobe Acrobat file Lupron, Synarel, Leuprolide Acetate.pdf 75.28 KB
An Adobe Acrobat file Marinol.pdf 69.72 KB
An Adobe Acrobat file Marqibo.pdf 67.93 KB
An Adobe Acrobat file Maxalt.pdf 73.51 KB
An Adobe Acrobat file Medical Exception Request Form.pdf 80.92 KB
An Adobe Acrobat file Mekinist.pdf 68.22 KB
An Adobe Acrobat file Methotrexate.pdf 67.29 KB
An Adobe Acrobat file Multi-Source Brand.pdf 68.36 KB
An Adobe Acrobat file Neulasta.pdf 70.23 KB
An Adobe Acrobat file Neumega.pdf 68.59 KB
An Adobe Acrobat file Neupogen,Leukine,Neulasta.pdf 76.57 KB
An Adobe Acrobat file Northera.pdf 69.03 KB
An Adobe Acrobat file Oral Contraceptives.pdf 68.47 KB
An Adobe Acrobat file Oral Oncology Agents.pdf 79.33 KB
An Adobe Acrobat file Orencia.pdf 72.63 KB
An Adobe Acrobat file Orenitram.pdf 68.4 KB
An Adobe Acrobat file Orfadin.pdf 68.62 KB
An Adobe Acrobat file Otezla.pdf 67.59 KB
An Adobe Acrobat file Oxycontin.pdf 69.1 KB
An Adobe Acrobat file PPI's.pdf 77.84 KB
An Adobe Acrobat file Panretin.pdf 68.6 KB
An Adobe Acrobat file Peg-Intron.pdf 70.26 KB
An Adobe Acrobat file Pegasys.pdf 69.17 KB
An Adobe Acrobat file Pneumovax.pdf 71.66 KB
An Adobe Acrobat file Pomalyst.pdf 79.1 KB
An Adobe Acrobat file Procrit - Aranesp.pdf 80.56 KB
An Adobe Acrobat file Proleukin.pdf 69.75 KB
An Adobe Acrobat file Protopic.pdf 71.05 KB
An Adobe Acrobat file Provigil.pdf 66.96 KB
An Adobe Acrobat file Pulmozyme.pdf 68.11 KB
An Adobe Acrobat file Qsymia PA.pdf 82.57 KB
An Adobe Acrobat file Quillivant XR.pdf 68.86 KB
An Adobe Acrobat file Ravicti.pdf 78.49 KB
An Adobe Acrobat file Remicade.pdf 69.99 KB
An Adobe Acrobat file Remodulin.pdf 68.35 KB
An Adobe Acrobat file Restasis.pdf 67.03 KB
An Adobe Acrobat file Risperdal Consta.pdf 70.2 KB
An Adobe Acrobat file Rituxan.pdf 71.62 KB
An Adobe Acrobat file Serostim.pdf 72.73 KB
An Adobe Acrobat file Signifor.pdf 78.74 KB
An Adobe Acrobat file Simponi.pdf 70.78 KB
An Adobe Acrobat file Simponi Aria.pdf 71.88 KB
An Adobe Acrobat file Sirturo.pdf 80.78 KB
An Adobe Acrobat file Smoking Cessation Products.pdf 66.52 KB
An Adobe Acrobat file Sovaldi.pdf 80.07 KB
An Adobe Acrobat file Sporanox.pdf 71.04 KB
An Adobe Acrobat file Stivargo.pdf 76.61 KB
An Adobe Acrobat file Strattera.pdf 71.25 KB
An Adobe Acrobat file Suboxone & Subutex.pdf 88.13 KB
An Adobe Acrobat file Supprelin LA.pdf 69.89 KB
An Adobe Acrobat file Synagis.pdf 71.53 KB
An Adobe Acrobat file Tafinlar.pdf 67.52 KB
An Adobe Acrobat file Tamiflu.pdf 71.07 KB
An Adobe Acrobat file Tarceva.pdf 77.04 KB
An Adobe Acrobat file Targretin.pdf 69 KB
An Adobe Acrobat file Tobi.pdf 78.83 KB
An Adobe Acrobat file Topical Testosterone.pdf 68.52 KB
An Adobe Acrobat file Tracleer & Letairis.pdf 71.38 KB
An Adobe Acrobat file Trokendi.pdf 75.51 KB
An Adobe Acrobat file Uceris.pdf 78.63 KB
An Adobe Acrobat file Valchlor.pdf 68.18 KB
An Adobe Acrobat file Valcyte.pdf 73.52 KB
An Adobe Acrobat file Xeljanz.pdf 69.04 KB
An Adobe Acrobat file Xeloda.pdf 75.79 KB
An Adobe Acrobat file Xenical.pdf 67.08 KB
An Adobe Acrobat file Xolair.pdf 76.1 KB
An Adobe Acrobat file Xyrem.pdf 68.28 KB
An Adobe Acrobat file Zubsolv.pdf 69.13 KB
An Adobe Acrobat file Zycadia.pdf 68.14 KB