Prior Authorization

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.

Prior Authorization

Filename Size
An Adobe Acrobat file ADD-ADHD 49.9 KB
An Adobe Acrobat file Abilify 85.05 KB
An Adobe Acrobat file Actiq - Fentora - Onsolis 51.69 KB
An Adobe Acrobat file Adempas 50.53 KB
An Adobe Acrobat file Alferon-N 78.68 KB
An Adobe Acrobat file Alprolix 83.44 KB
An Adobe Acrobat file Anti-Hemophilic Factor 79.8 KB
An Adobe Acrobat file Anticoagulants 80.87 KB
An Adobe Acrobat file Aptiom 50.6 KB
An Adobe Acrobat file Aranesp 80.75 KB
An Adobe Acrobat file Arava 50.99 KB
An Adobe Acrobat file Aubagio 50.54 KB
An Adobe Acrobat file Avonex, Rebif 51.07 KB
An Adobe Acrobat file Belviq 51.32 KB
An Adobe Acrobat file Betaseron 50.72 KB
An Adobe Acrobat file Bosulif 83.32 KB
An Adobe Acrobat file Brand Medically Necessary 51.64 KB
An Adobe Acrobat file Byetta 50.67 KB
An Adobe Acrobat file Celebrex 80.19 KB
An Adobe Acrobat file Cimzia 85.63 KB
An Adobe Acrobat file Cometriq 93.01 KB
An Adobe Acrobat file Copaxone 79.49 KB
An Adobe Acrobat file Copegus, Rebetol, Ribasphere, Ribapak, Virazole, Ribavirin 51.63 KB
An Adobe Acrobat file Cyramza 50.57 KB
An Adobe Acrobat file Cystaran 50.11 KB
An Adobe Acrobat file Cytoxan 106.03 KB
An Adobe Acrobat file Dexedrine Spansule 50.8 KB
An Adobe Acrobat file Egrifta 83.62 KB
An Adobe Acrobat file Elidel 50.81 KB
An Adobe Acrobat file Emend 50.56 KB
An Adobe Acrobat file Enbrel 82.03 KB
An Adobe Acrobat file Farxiga 50.31 KB
An Adobe Acrobat file Flolan 49.98 KB
An Adobe Acrobat file Forteo 80.46 KB
An Adobe Acrobat file Fuzeon 79.52 KB
An Adobe Acrobat file Gattex 81.05 KB
An Adobe Acrobat file General PA Form 79.33 KB
An Adobe Acrobat file Gilotrif 50.54 KB
An Adobe Acrobat file Hemangeol 79.62 KB
An Adobe Acrobat file Hepatitis B Vaccine 79.55 KB
An Adobe Acrobat file Hepatitis C 80.8 KB
An Adobe Acrobat file Hepsera 55.92 KB
An Adobe Acrobat file Hetlioz 50.14 KB
An Adobe Acrobat file Human Growth Hormone for Adults 83.55 KB
An Adobe Acrobat file Human Growth Hormone for Children_Non-Preferred 83.42 KB
An Adobe Acrobat file Human Growth Hormone for HIV Wasting in Adults 82.4 KB
An Adobe Acrobat file Humira 87.37 KB
An Adobe Acrobat file Iclusig 50.62 KB
An Adobe Acrobat file Immune Globulins 80.98 KB
An Adobe Acrobat file Immunosuppressive Agents 50.58 KB
An Adobe Acrobat file Increlex 85.68 KB
An Adobe Acrobat file Infertility Medications 80.88 KB
An Adobe Acrobat file Injectafer 50.39 KB
An Adobe Acrobat file Intron-A 81.84 KB
An Adobe Acrobat file Isotretinoin 64.85 KB
An Adobe Acrobat file Juxtapid 51.01 KB
An Adobe Acrobat file Kynamro 50.25 KB
An Adobe Acrobat file Kyprolis 50.45 KB
An Adobe Acrobat file Lamisil 52.01 KB
An Adobe Acrobat file Lazanda 51.46 KB
An Adobe Acrobat file Lemtrada 98.98 KB
An Adobe Acrobat file Leukine 81.03 KB
An Adobe Acrobat file Liptruzet 50.33 KB
An Adobe Acrobat file Lotronex 81.76 KB
An Adobe Acrobat file Lupron, Synarel, Leuprolide Acetate 79.38 KB
An Adobe Acrobat file Marinol 51.06 KB
An Adobe Acrobat file Marqibo 50.52 KB
An Adobe Acrobat file Maxalt 84.47 KB
An Adobe Acrobat file Medical Exception Request Form 92.26 KB
An Adobe Acrobat file Mekinist 50.22 KB
An Adobe Acrobat file Methotrexate 77.98 KB
An Adobe Acrobat file Multi-Source Brand 50.41 KB
An Adobe Acrobat file Neulasta 50.97 KB
An Adobe Acrobat file Neumega 50.48 KB
An Adobe Acrobat file Neupogen,Leukine,Neulasta 80.05 KB
An Adobe Acrobat file Northera 50.47 KB
An Adobe Acrobat file Oral Contraceptives 50.54 KB
An Adobe Acrobat file Oral Oncology Agents 94.68 KB
An Adobe Acrobat file Orencia 81.59 KB
An Adobe Acrobat file Orenitram 50.12 KB
An Adobe Acrobat file Orfadin 50.36 KB
An Adobe Acrobat file PPI's 65.45 KB
An Adobe Acrobat file Panretin 50.09 KB
An Adobe Acrobat file Peg-Intron 50.87 KB
An Adobe Acrobat file Pegasys 50.74 KB
An Adobe Acrobat file Pneumovax 80.51 KB
An Adobe Acrobat file Pomalyst 50.75 KB
An Adobe Acrobat file Praluent 150.91 KB
An Adobe Acrobat file Procrit - Aranesp 128.36 KB
An Adobe Acrobat file Proleukin 79.33 KB
An Adobe Acrobat file Protopic 51.03 KB
An Adobe Acrobat file Provigil 80.1 KB
An Adobe Acrobat file Pulmozyme 50.37 KB
An Adobe Acrobat file Qsymia PA 51.65 KB
An Adobe Acrobat file Quillivant XR 50.38 KB
An Adobe Acrobat file Ravicti 50.65 KB
An Adobe Acrobat file Remicade 80.06 KB
An Adobe Acrobat file Remodulin 50 KB
An Adobe Acrobat file Repatha 150.91 KB
An Adobe Acrobat file Restasis 49.89 KB
An Adobe Acrobat file Risperdal Consta 80.15 KB
An Adobe Acrobat file Rituxan 81.11 KB
An Adobe Acrobat file Serostim 50.29 KB
An Adobe Acrobat file Signifor 50.89 KB
An Adobe Acrobat file Simponi 80.72 KB
An Adobe Acrobat file Simponi Aria 49.89 KB
An Adobe Acrobat file Sirturo 50.83 KB
An Adobe Acrobat file Smoking Cessation Products 49.82 KB
An Adobe Acrobat file Sporanox 80.7 KB
An Adobe Acrobat file Stivarga 50.89 KB
An Adobe Acrobat file Strattera 79.88 KB
An Adobe Acrobat file Suboxone & Subutex 91.68 KB
An Adobe Acrobat file Supprelin LA 51.31 KB
An Adobe Acrobat file Synagis 81.62 KB
An Adobe Acrobat file Tafinlar 50.73 KB
An Adobe Acrobat file Tamiflu 91.47 KB
An Adobe Acrobat file Tarceva 65.43 KB
An Adobe Acrobat file Targretin 51.11 KB
An Adobe Acrobat file Tobi 93.88 KB
An Adobe Acrobat file Topical Testosterone 51.13 KB
An Adobe Acrobat file Tracleer and Letairis 52.37 KB
An Adobe Acrobat file Trokendi 64.52 KB
An Adobe Acrobat file Uceris 65.23 KB
An Adobe Acrobat file Valchlor 50.8 KB
An Adobe Acrobat file Valcyte 115.21 KB
An Adobe Acrobat file Xeljanz 52.09 KB
An Adobe Acrobat file Xeloda 64.71 KB
An Adobe Acrobat file Xenical 50.66 KB
An Adobe Acrobat file Xolair 82.44 KB
An Adobe Acrobat file Xyrem 51.04 KB
An Adobe Acrobat file Zubsolv 51.46 KB
An Adobe Acrobat file Zykadia 50.76 KB
An Adobe Acrobat file entyvio 79.84 KB

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