Prior Authorization

Authorizations

To prior authorize services or treatments for your patients, please complete and return the appropriate form below. If you have any questions, please call our Medical Management team at 1-855-458-4928.

Prior Authorization Requirements

Prior Authorization Requirements

Click on the button below to view the Prior Authorization List.

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Radiology Program & Genetic and Genomic Testing Program

Effective 2/1/2017 , please fax requests for a retrospective authorization to HealthyCT at 855-817-5696 using the General Authorization Request Form for Medical Services. Appeals should be faxed to HealthyCT at 855-817-5697

RX Prior Authorization Forms
Abstral
Accolate
Actemra
Acthar HP
Actiq
Adcetris
Adcirca
Addyi
Adempas
Advicor
Afinitor
Afrezza
Aldurazyme
Alecensa
Allergen Specific Immunotherapy
Almotriptan
Alpha 1 Proteinase Inhibitors
Alsuma
Altoprev
Alvesco
Amino Acid Modified Preparations
Ampyra
Anabolic Steroids
Anadrol
Androderm
Angiotensin II Receptor Blockers (ARBs)
Anti Emetics (Quantity Limit)
Antifungal Agents
Antipsoriatic Topical Agents
Antispasmodics
Apidra
Apokyn
Apriso
Aralast
Aranesp
Arcalyst
Arixtra (Quantity Limit)
Arzerra
Asacol HD
Asmanex
Atralin
Attention Deficit Hyperactivity Disorder (ADHD) (Quantity Limit)
Atypical Antipsychotic Agents
Aubagio
Aveed
Avita
Avonex
Axert
Axiron
Baraclude
Belbuca
Beleodaq
Benlysta
Beta Agonists (Inhaled)
Betaseron
Bethkis
Bisphosphonates
Bivigam
Blincyto
Bosulif
Botox
Brand Medically Necessary
Bravelle
Bunavail
Butrans
Bydureon
Byetta
CNL8
CNS Stimulants
Candesartan
Cannabinoids
Caprelsa
Carimune NF
Cayston
Central Nervous System (CNS) Stimulants
Cerdelga
Cerezyme
Cesamet
Cetrotide
Cholbam
Chorionic Gonadotropin
Cialis for Benign Prostatic Hyperplasia (BPH)
Ciclodan
Ciclopirox
Cimzia
Colony Stimulating Factors
Cometriq
Compounded Rx Standard
Compounded Rx with Diclofenac
Compounded Rx with Flurbiprofen
Compounded Rx with Fluticasone
Compounded Rx with Gabapentin
Compounded Rx with Ketamine
Compounded Rx with Ketoprofen
Compounded Rx with Levocetirizine
Compounded Rx with Mometasone
Copaxone
Corlanor
Cosentyx
Cotellic
Cyramza
Cystaran
Cystic Fibrosis, Inhaled Agents
Cytogam
DPP 4 Inhibitors
Dacogen
Daklinza
Darzalex
Deferasirox
Delatestryl
Delzicol
Depo Testosterone
Diclegis
Differin
Dipeptidyl Peptidase 4 (DPP 4) Inhibitors
Dispense As Written (DAW)
Dulera
Dysport
Ecoza
Edarbi
Egrifta
Elaprase
Elelyso
Eligard
Empliciti
Enablex
Enbrel
Endothelin Receptor Antagonists
Enstilar
Entresto
Entyvio
Epiduo
Epogen
Epoprostenol
Erivedge
Ertaczo
Esbriet
Euflexxa
Exelderm
Exjade
Extavia
Fabior
Fabrazyme
Fanapt
Farxiga
Farydak
Fentanyl Short Acting Agents
Fentora
Ferriprox
Fertility Agents
Firmagon
Flebogamma DIF
Flector
Flolan
Follistim AQ
Formulary Override Exception
Fortesta
Fragmin (Quantity Limit)
Frova
Fulyzaq
Gamastan SD
Gammagard Liquid
Gammagard SD
Gammaked
Gammaplex
Gamunex C
Ganirelix Acetate
Gattex
Gazyva
Gel One
Gel Syn
Genotropin
Genvisc 850
Gilenya
Gilotrif
Glassia
Glatiramer Acetate
Glatopa
Gleevec
Glucagon Like Peptide 1 (GLP 1) Agonists
Glucose Test Strips
Glyxambi
Gonal F
Gralise
Granix
Grastek
Growth Hormones
HP Acthar
Halaven
Harvoni
Hepatitis B Agents
Hepsera
Herceptin
Hetlioz
High Dollar Override
Hizentra
Horizant
Humalog
Humatrope
Humira
Humulin
Hyalgan
Hyaluronic Acid Derivatives
Hyqvia
IVIG
Ibandronate IV
Ibrance
Iclusig
Ilaris
Imbruvica
Immune Globulins
Increlex
Infertility Agents
Inhaled Corticosteroid Long Acting Beta Agonist (LABA) Combinations
Inhaled Corticosteroids (ICS)
Inlyta
Insulins (Long Acting)
Insulins (Short Acting)
Interferons for Multiple Sclerosis
Interleukins
Intron A
Invokamet
Invokana
Iressa
Irritable Bowel Syndrome (IBS) Agents
Istodax
Jadenu
Jakafi
Janumet
Januvia
Jardiance
Jentadueto
Jevtana
Jublia
Juxtapid
Kadcyla
Kalydeco
Kanuma
Kazano
Kerydin
Keveyis
Keytruda
Kineret
Kitabis
Kombiglyze
Korlym
Krystexxa
Kuvan
Kynamro
Kyprolis
Lazanda
Lemtrada
Lenvima
Lescol XL
Letairis
Leukine
Leukotriene Modifiers
Levemir
Liptruzet
Livalo
Lonsurf
Lovenox (Quantity Limit)
Low Molecular Weight Heparin (LMWH) (Quantity Limit)
Low Protein Modified Food Products
Lumizyme
Lupaneta Pack
Lupron
Luzu
Lynparza
Makena
Marinol
Mekinist
Menopur
Mentax
Migraine Agents
Migraine Agents (Quantity Limit)
Mircera
Mitoxantrone
Monovisc
Movantik
Mozobil
Multiple Sclerosis Agents
Myalept
Myobloc
Myozyme
Naftin
Naglazyme
Natesto
Natpara
Nesina
Neulasta
Neumega
Neupogen
Neupro
New Drug to Market
Nexavar
Ninlaro
Non Formulary Exceptions
Norditropin
Northera
Novantrone
Novarel
Nplate
Nucala
Nulojix
Nutropin
Nuvigil
Octagam
Odomzo
Ofev
Olysio
Omnitrope
Omontys
Onglyza
Onmel
Onsolis
Opdivo
Opioid Dependence Agents
Opioid Receptor Agonists
Opsumit
Oralair
Orencia
Orenitram
Orkambi
Orthovisc
Oseni
Otezla
Oxandrin
Oxistat
PDE 5 Inhibitors for Pulmonary Arterial Hypertension (PAH)
Paliperidone
Pancreatic Enzymes
Pancreaze
Pedipirox
PegIntron
Pegasys
Pennsaid
Perjeta
Pertzye
Plegridy
Pomalyst
Portrazza
Praluent
Pregnyl
Preventative Drug Benefit
Privigen
Procrit
Procysbi
Prolastin
Prolia
Promacta
Prostanoids
Proton Pump Inhibitor (PPI) (Quantity Limit)
Provenge
Proventil HFA
Provigil
Pulmonary Fibrosis Agents
Pulmozyme
Qualaquin
Qutenza
Ragwitek
Ranexa
Ravicti
Rebif
Reclast
Regranex
Relistor
Relpax
Remicade
Remodulin
Repatha
Repronex
Restasis
Retin A
Revatio
Revlimid
Rilutek
Risedronate
Rituxan
Sabril
Saizen
Samsca (Quantity Limit)
Sandostatin
Saphris
Savella
Selzentry
Sensipar
Serostim
Short Acting Opioids (Quantity Limit)
Signifor
Sildenafil for Pulmonary Arterial Hypertension (PAH)
Simcor
Simponi
Simvastatin 80mg
Sodium Glucose Co Transporter 2 (SGLT 2) Inhibitors
Soliris
Somatostatin Analogs
Somatuline
Somavert
Sovaldi
Specialized Formulas
Sporanox
Sprycel
Statins
Stelara
Stivarga
Strensiq
Striant
Suboxone
Subsys
Subutex
Sumavel
Supartz
Supprelin LA
Sutent
Sylatron
Sylvant
Symlin
Synagis
Synjardy
Synribo
Synvisc
Taclonex
Tafinlar
Tagrisso
Tanzeum
Tarceva
Targretin
Tasigna
Tazorac
Tecfidera
Technivie
Temodar
Testim
Testopel
Testosterone (Injectable)
Testosterone (Topical)
Thalomid
Thrombopoietin Receptor Agonists
Thyrogen
Tobi
Topical Antifungals Agents
Topical Retinoid Agents
Tracleer
Tradjenta
Trelstar
Tretin X
Treximet
Triptans for Migraine
Trulicity
Tykerb
Tysabri
Tyvaso
Tyzeka
Ultressa
Uptravi
Valchlor
Vantas
Variziq
Velcade
Veltin
Ventavis
Victoza
Vidaza
Viekira
Vimizim
Viokace
Viscosupplements
Vogelxo
Votrient
Vpriv
Vytorin
Vytorin 10-80mg
Xalkori
Xeljanz
Xeloda
Xenazine
Xeomin
Xgeva
Xiaflex
Xifaxan
Xigduo XR
Xolair
Xolegel
Xopenex HFA
Xtandi
Xuriden
Xyrem
Yervoy
Zaltrap
Zarxio
Zavesca
Zecuity
Zelboraf
Zemaira
Zenpep
Zepatier
Ziana
Zohydro
Zolinza
Zomacton
Zometa
Zomig
Zorbtive
Zortress
Zubsolv
Zydelig
Zyflo
Zykadia
Zytiga