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 (8:00 AM - 8:00 PM, Monday through Friday, and 9:00 AM - 1:00 PM ET Saturday) 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 & Therapeutics Committee.

Prior Authorization

Filename
An Adobe Acrobat file ADD-ADHD
An Adobe Acrobat file Abilify
An Adobe Acrobat file Actiq - Fentora - Onsolis
An Adobe Acrobat file Adempas
An Adobe Acrobat file Alferon-N
An Adobe Acrobat file Alprolix
An Adobe Acrobat file Anti-Hemophilic Factor
An Adobe Acrobat file Anticoagulants
An Adobe Acrobat file Aptiom
An Adobe Acrobat file Aranesp
An Adobe Acrobat file Arava
An Adobe Acrobat file Aubagio
An Adobe Acrobat file Avonex, Rebif
An Adobe Acrobat file Belviq
An Adobe Acrobat file Betaseron
An Adobe Acrobat file Bosulif
An Adobe Acrobat file Brand Medically Necessary
An Adobe Acrobat file Byetta
An Adobe Acrobat file Celebrex
An Adobe Acrobat file Cimzia
An Adobe Acrobat file Cometriq
An Adobe Acrobat file Copaxone
An Adobe Acrobat file Copegus, Rebetol, Ribasphere, Ribapak, Virazole, Ribavirin
An Adobe Acrobat file Cyramza
An Adobe Acrobat file Cystaran
An Adobe Acrobat file Cytoxan
An Adobe Acrobat file Dexedrine Spansule
An Adobe Acrobat file Egrifta
An Adobe Acrobat file Elidel
An Adobe Acrobat file Emend
An Adobe Acrobat file Enbrel
An Adobe Acrobat file Entyvio
An Adobe Acrobat file Farxiga
An Adobe Acrobat file Flolan
An Adobe Acrobat file Forteo
An Adobe Acrobat file Fuzeon
An Adobe Acrobat file Gattex
An Adobe Acrobat file General PA Form
An Adobe Acrobat file Gilotrif
An Adobe Acrobat file Hemangeol
An Adobe Acrobat file Hepatitis B Vaccine
An Adobe Acrobat file Hepatitis C
An Adobe Acrobat file Hepsera
An Adobe Acrobat file Hetlioz
An Adobe Acrobat file Human Growth Hormone for Adults
An Adobe Acrobat file Human Growth Hormone for Children_Non-Preferred
An Adobe Acrobat file Human Growth Hormone for HIV Wasting in Adults
An Adobe Acrobat file Humira
An Adobe Acrobat file Iclusig
An Adobe Acrobat file Immune Globulins
An Adobe Acrobat file Immunosuppressive Agents
An Adobe Acrobat file Increlex
An Adobe Acrobat file Infertility Medications
An Adobe Acrobat file Injectafer
An Adobe Acrobat file Intron-A
An Adobe Acrobat file Isotretinoin
An Adobe Acrobat file Juxtapid
An Adobe Acrobat file Kynamro
An Adobe Acrobat file Kyprolis
An Adobe Acrobat file Lamisil
An Adobe Acrobat file Lazanda
An Adobe Acrobat file Lemtrada
An Adobe Acrobat file Leukine
An Adobe Acrobat file Liptruzet
An Adobe Acrobat file Lotronex
An Adobe Acrobat file Lupron, Synarel, Leuprolide Acetate
An Adobe Acrobat file Marinol
An Adobe Acrobat file Marqibo
An Adobe Acrobat file Maxalt
An Adobe Acrobat file Medical Exception Request Form
An Adobe Acrobat file Mekinist
An Adobe Acrobat file Methotrexate
An Adobe Acrobat file Multi-Source Brand
An Adobe Acrobat file Neulasta
An Adobe Acrobat file Neumega
An Adobe Acrobat file Neupogen,Leukine,Neulasta
An Adobe Acrobat file Northera
An Adobe Acrobat file Oral Contraceptives
An Adobe Acrobat file Oral Oncology Agents
An Adobe Acrobat file Orencia
An Adobe Acrobat file Orenitram
An Adobe Acrobat file Orfadin
An Adobe Acrobat file PPI's
An Adobe Acrobat file Panretin
An Adobe Acrobat file Peg-Intron
An Adobe Acrobat file Pegasys
An Adobe Acrobat file Pneumovax
An Adobe Acrobat file Pomalyst
An Adobe Acrobat file Praluent
An Adobe Acrobat file Procrit - Aranesp
An Adobe Acrobat file Proleukin
An Adobe Acrobat file Protopic
An Adobe Acrobat file Provigil
An Adobe Acrobat file Pulmozyme
An Adobe Acrobat file Qsymia PA
An Adobe Acrobat file Quillivant XR
An Adobe Acrobat file Ravicti
An Adobe Acrobat file Remicade
An Adobe Acrobat file Remodulin
An Adobe Acrobat file Repatha
An Adobe Acrobat file Restasis
An Adobe Acrobat file Risperdal Consta
An Adobe Acrobat file Rituxan
An Adobe Acrobat file Serostim
An Adobe Acrobat file Signifor
An Adobe Acrobat file Simponi
An Adobe Acrobat file Simponi Aria
An Adobe Acrobat file Sirturo
An Adobe Acrobat file Smoking Cessation Products
An Adobe Acrobat file Sporanox
An Adobe Acrobat file Stivarga
An Adobe Acrobat file Strattera
An Adobe Acrobat file Suboxone & Subutex
An Adobe Acrobat file Supprelin LA
An Adobe Acrobat file Synagis
An Adobe Acrobat file Tafinlar
An Adobe Acrobat file Tamiflu
An Adobe Acrobat file Tarceva
An Adobe Acrobat file Targretin
An Adobe Acrobat file Tobi
An Adobe Acrobat file Topical Testosterone
An Adobe Acrobat file Tracleer and Letairis
An Adobe Acrobat file Trokendi
An Adobe Acrobat file Uceris
An Adobe Acrobat file Valchlor
An Adobe Acrobat file Valcyte
An Adobe Acrobat file Xeljanz
An Adobe Acrobat file Xeloda
An Adobe Acrobat file Xenical
An Adobe Acrobat file Xolair
An Adobe Acrobat file Xyrem
An Adobe Acrobat file Zubsolv
An Adobe Acrobat file Zykadia

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