HealthChoice Medicare Supplement Plans
Medications Requiring Prior Authorization

Prior authorization is always needed for certain drugs even though they are listed in the HealthChoice Medicare Formulary.  Prior authorization is required if the drug:

• Has a very high cost
• Has specific prescribing guidelines
• Might be covered under Medicare Part B
• Is generally used for cosmetic purposes

A request for prior authorization must be submitted by your physician.  Your request must be approved before you fill your prescription.  To apply:

1. Have your physician’s office contact Express Scripts toll-free at 1-800-753-2851. Your physician’s office will need to have your member ID and medication name available.
2. Express Scripts will fax a Prior Authorization Form to your physician’s office and request that it be completed and faxed back.
3. If your prior authorization is approved, your physician’s office will receive notice of the approval within 24 to 48 hours.  You will also be notified in writing.
4. If your prior authorization is denied because it does not meet clinical criteria, your physician’s office will receive notice of denial within 24 to 48 hours.  You will also be notified in writing.

Note:  A prior authorization is valid for one year from the date it is issued and must be renewed when it expires. 

Use the links below to go to the different medication categories and then find your medication in the list. To read the reasons your medication requires prior authorization, simply click on the medication name. Please note this list is not all inclusive and is subject to change.

ADRENAL HORMONES
ANTI - INFECTIVES / ANTI - FUNGAL AGENTS
ANTI - INFECTIVES / ANTI - VIRALS
ANTI - INFECTIVES / MISCELLANEOUS
ANTI - NEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
BIOTECHNOLOGY DRUGS - ALFA INTERFERONS
BIOTECHNOLOGY DRUGS - ALFA INTERFERONS PEGYLATED
BIOTECHNOLOGY DRUGS - COLONY STIMULATING FACTORS
BIOTECHNOLOGY DRUGS - DARBEPOETIN ALFA/ EPOETIN ALFA
BIOTECHNOLOGY DRUGS - GROWTH HORMONES
BIOTECHNOLOGY DRUGS - MISCELLANEOUS HORMONES
BIOTECHNOLOGY DRUGS - NEUMEGA
CNS STIMULANTS
COAGULATION THERAPY
ERECTILE DYSFUNCTION
ESTROGENS/PROGESTINS
GASTROENTEROLOGY
GOUT THERAPY
MISCELLANEOUS HORMONES
MISCELLANEOUS HORMONES - ANDROGENS
MISCELLANEOUS PULMONARY AGENTS
MULTIPLE SCLEROSIS THERAPY
MUSCLE RELAXANTS / ANTI - SPASMODIC THERAPY
NITRATES
NON-NARCOTIC ANALGESICS
OSTEOPOROSIS THERAPY
PULMONARY AGENTS
RHEUMATOLOGICALS
TOPICAL ANESTHETICS
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
VACCINES / MISCELLANEOUS IMMUNOLOGICALS - IMMUNE GLOBULINS

ADRENAL HORMONES 

methylprednisolone - oral tablet
prednisolone sodium phosphate - oral solution
prednisone - oral solution, oral tablet
PREDNISONE INTENSOL- oral concentrate

ANTI-INFECTIVES / ANTI-FUNGAL AGENTS 

amphotericin b - injection solution reconstituted

ANTI-INFECTIVES / ANTI-VIRALS 

foscarnet sodium - injection solution
INCIVEK - oral capsule
REBETOL - oral solution
RIBAPAK - oral tabs
RIBASPHERE - oral capsules, oral tabs
RIBAVIRIN - oral capsules, oral tabs
VICTRELIS - oral capsule

ANTI-INFECTIVES MISCELLANEOUS  

CUBICIN  - injection solution reconstituted
NEBUPENT - inhalation solution reconstituted
TOBI - inhalation nebulized solution
vancomycin hcl- injection solution

ANTI-NEOPLASTIC / IMMUNOSUPPRESSANT DRUGS 

AFINITOR - oral tablet
CELLCEPT - oral capsule, oral suspension reconstituted, oral tablet
cyclophosphamide - oral tablet
cyclosporine - oral capsule, injection solution
cyclosporine modified - oral capsule, oral solution
ERIVEDGE  - oral capsule
GENGRAF - oral capsule, oral solution
INLYTA - oral tablet
JAKAFI - oral tablet
methotrexate - oral tablet
mycophenolate mofetil - oral capsule, oral tablet
MYFORTIC - oral tablet delayed release
NEORAL - oral capsule, oral solution
NEXAVAR - oral tablet
RAPAMUNE - oral solution, oral tablet
RHEUMATREX - oral tablet
RITUXAN - concentrate
SANDIMMUNE - oral capsule, injection solution, oral solution
SUTENT - oral capsule
tacrolimus - oral capsule
TARCEVA - oral tablet
THALOMID - oral capsule
TORISEL - injection solution
XALKORI - oral capsule
XGEVA - injection solution
YERVOY - injection solution
ZELBORAF - oral tablet
ZORTRESS - oral tablet
ZYTIGA - oral tablet

BIOTECHNOLOGY DRUGS - ALFA INTERFERONS 

INTRON-A W/DILUENT - injection solution
INTRON-A  - injection solution

BIOTECHNOLOGY DRUGS - ALFA INTERFERONS PEGYLATED 

PEG-INTRON - injections solution
PEG-INTRON REDIPEN - injection solution
PEGASYS - injection solution
PEGASYS PROCLICK - injection solution
SYLATRON - injection solution

BIOTECHNOLOGY DRUGS - COLONY STIMULATING FACTORS 

LEUKINE - injection solution reconstituted
NEULASTA - injection solution
NEUPOGEN - injection solution

BIOTECHNOLOGY DRUGS - DARBEPOETIN ALFA / EPOETIN ALFA 

ARANESP - injection solution
EPOGEN - injection solution
PROCRIT - injection solution

BIOTECHNOLOGY DRUGS - GROWTH HORMONES 

NORDITROPIN FLEXPRO - injection solution
NORDITROPIN NORDIFLEX PEN - injection solution
OMNITROPE - injection solution

BIOTECHNOLOGY DRUGS - MISCELLANEOUS HORMONES 

SOMAVERT - injection solution reconstituted

BIOTECHNOLOGY DRUGS - NEUMEGA 

NEUMEGA - injection solution reconstituted

CNS STIMULANTS 

dextroamphetamine sulfate - oral tablet
dextroamphetamine sulfate er - oral capsule
FOCALIN XR - oral capsule
METADATE CD - oral capsule
methylphenidate hcl- oral tablet
methylphenidate hcl oral tablet, oral solution
RITALIN LA - oral capsule
modafinil - oral tablet

COAGULATION THERAPY 

PROMACTA - oral tablet

ERECTILE DYSFUNCTION 

CAVERJECT - injection solution
CIALIS - oral tablet
LEVITRA - oral tablet
MUSE - oral tablet
VIAGRA - oral tablet

ESTROGENS / PROGESTINS 

CRINONE - gel

GASTROENTEROLOGY 

dronabinol - oral capsule
EMEND - oral capsule
granisetron - oral tablet
ondansetron hcl - oral solution, oral tablet
ondansetron otd - oral tablet dispersible

GOUT THERAPY 

ULORIC - oral tablet

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY 

NEUPOGEN - injection solution
RECOMBIVAX HB - injection suspension
TEV-TROPIN - injection solution reconstituted
TWINRIX - injection suspension
VIVAGLOBIN - injection solution

MISCELLANEOUS AGENTS 

levocarnitine - solution, oral tablet

MISCELLANEOUS HORMONES 

calcitriol - oral capsules, solution
ZEMPLAR - oral capsule, injection solution

MISCELLANEOUS HORMONES - ANDROGENS 

ANDROGEL - topical gel
ANDROGEL PUMP- topical gel
androxy - oral tablet
testosterone cypionate - oil
testosterone enanthate - oil

MISCELLANEOUS PULMONARY AGENTS 

LETAIRIS - oral tablet
REMODULIN - injection solution
REVATIO - oral tablet
TRACLEER - oral tablet
XOLAIR - injection solution reconstituted

MUSCLE RELAXANTS / ANTI-SPASMODIC THERAPY 

lioresal intrathecal- injection solution

MULTIPLE SCLEROSIS THERAPY 

AVONEX - injection solution
COPAXONE - kit
GILENYA - oral capsule
BETASERON - injection solution reconstituted
REBIF - injection solution
REBIF TITRATION PACK- injection solution

NITRATES 

nitroglycerin - injection solution

NON-NARCOTIC ANALGESICS 

CELEBREX - oral capsule

OSTEOPOROSIS THERAPY 

ibandronate sodium - oral tablet

PULMONARY AGENTS 

acetylcysteine - inhalation solution
albuterol sulfate - inhalation nebulization solution
budesonide - inhalation solution
cromolyn sodium - inhalation nebulization solution
ipratropium bromide - inhalation solution
ipratropium bromide/albuterol sulfate - inhalation solution
PERFOROMIST - inhalation solution
PULMICORT - inhalation suspension
PULMOZYME - inhalation solution

RHEUMATOLOGICALS 

CIMZIA - kit
ENBREL - injection solution
HUMIRA - kit
ORENCIA - injection solution
REMICADE - injection solution
SIMPONI - injection solution

TOPICAL ANESTHETICS 

LIDODERM

VACCINES / MISCELLANEOUS IMMUNOLOGICALS 

ENGERIX-B - injection suspension
RECOMBIVAX HB - injection suspension

VACCINES / MISCELLANEOUS IMMUNOLOGICALS - IMMUNE GLOBULINS 

HIZENTRA - injection solution
PRIVIGEN - injection solution