Prior authorization forms for prescription drugs

ABSTRAL (Fentanyl sublingal)
ACTEMRA (Tocilizumab)
ADCIRCA (Tadalafil)
ADEMPAS (Riociguat)
AFINITOR (Everolimus)
AIMOVIG (Erenumab)
ALECENSARO (Alectinib)
ALUNBRIG (Brigatinib)
  • FV6968 (PDF, 111 ko) – First-line treatment ALK+ locally advanced or metastatic non-small cell lung cancer (NSCLC)
APTIOM (Eslicarbazepine acetate)
AUBAGIO (Teriflunomide)
BANZEL (Rufinamide)
BENLYSTA (Belimumab)
BOSULIF (Bosutinib)
BOTOX (Botulinum toxin)
BRENZYS (Etanercept)
BRIVLERA (Brivaracetam)
CAPRELSA (Vandetanib)
CEENU (Lomustine)
CIALIS (Tadalafil)
CIMZIA (Certolizumab pegol)
CINQAIR (Reslizumab)
CONTRAVE (Naltrexone/Bupropion)
COPAXONE (Glatiramere acetate)
COSENTYX (Secukinumab)
COTELLIC (Cobimetinib)
CRINONE (Progesterone)
CYSTADROPS (Cystéamine)
DAKLINZA (Daclatasvir)
DIACOMIT (Stiripentol)
DUODOPA (Levodopa / Carbidopa)
DUPIXENT (Dupulumab)
DYSPORT (Botulinum toxin)
EGRIFTA (Tesamorelin)
ENBREL (Etanercept)
ENDOMETRIN (Progesterone)
ENTYVIO (Vedolizumab)
EPCLUSA (Sofosbuvir/Velpatasvir)
ERELZI (Etanercept)
ERIVEDGE (Vismodegib)
ESBRIET (Pirfenidone)
EXJADE (Deferasirox)
EYLEA (Aflibercept)
FAMPYRA (Fampridine)
FAMPYRA (Fampridine)
FASENRA (Benralizumab)
FIRAZYR (Icatibant)
FORTEO (Teriparatide)
FYCOMPA (Perampanel)
GALAFOLD (Migalast)
GALEXOS (Simeprevir)
GENOTROPIN (Somatropin)
GILENYA (Fingolimod)
GIOTRIF (Afatinib)
GLEEVEC (Imatinib)
HARVONI (Ledipasvir / Sofosbuvir )
HCG (Chorionic Gonadotropin)
HOLKIRA PAK (Ombitasvir / Paritaprevir / Ritonavir / Dasabuvir)
HUMATROPE (Somatropin)
HUMIRA (Adalimumab)
IBAVYR (Ribavirin)
IBRANCE (Palbociclib)
ICLUSIG (Ponitinib hydrochloride)
ILARIS (Canakinumab)
IMBRUVICA (Ibrutinib)
INCIVEK (Telaprevir)
INFLECTRA (Infliximab)
INLYTA (Axitinib)
IRESSA (Gefitinib)
JADENU (Deferasirox)
JAKAVI (Ruxolitinib)
JETREA (Ocriplasmine)
JINARC (Tolvaptan)
JUXTAPID (Lomitapide)
KALYDECO (Ivacaftor)
KETALAR (Ketamine)
KEVZARA (Sarilumab)
KINERET (Anakinra)
KISQALI (Ribociclib)
KUVAN (Sapropterin Dihydrochloride)
LANTUS (Insulin glargine)
LEMTRADA (Alemtuzumab)
LENVIMA (Lenvatinib)
LEVITRA (Vardenafil)
LEVULAN (Aminolevulinic Acid)
LOBRENA (Lorlatinib)
LONSURF (Trifluridine)
LUCENTIS (Ranibizumab)
LYNPARZA (Olaparib)
MATULANE (Procarbazine HCL)
MAVENCLAD (Cladribine)
MAVIRET (Glécaprévir/Pibrentasvir)
MEKINIST (Trametinib)
MENOPUR (Menotropins)
METVIX (Methyl Aminolevulinate)
MOVAPO (Apomorphine hydrochloride)
MYOZYME (Alglucosidase alfa)
NEUPOGEN (Filgrastim)
NEXAVAR (Sorafenib)
NINLARO (Ixazomib)
NORDITROPIN (Somatropin )
NPLATE (Romiplostim)
NUCALA (Mepolizumab)
NUTROPIN (Somatropin)
OCALIVA (Obeticholic acid)
OCREVUS (Ocrelizumab)
OFEV (Nintedanib)
OMNITROPE (Somatropin)
ORENCIA (Abatacept)
ORFADIN (Nitisinone)
ORKAMBI (Lumacaftor / Ivacaftor)
OTEZLA (Apremilast)
OZURDEX (Dexamethasone)
PEGASYS (Peginterferon alfa-2a)
PEGASYS ± RBV (Peginterferon alfa-2a ± ribavirin)
PEGETRON (Interferon alfa-2b / ribavirin)
PHEBURANE (Sodium phenylbutyrate)
POMALYST (Pomalidomide)
PRALUENT (Alirocumab)
PREGNYL (Chorionic gonadotropin)
PREVYMIS (Letermovir)
PROCYSBI (Cysteamine)
PULMOZYME INHALATION (Dornase Alfa)
RAVICTI (Glycerol phenylbutyrate)
REMICADE (Infliximab)
RENFLEXIS (Infliximab)
REPATHA (Evolocumab)
REPRONEX (Menotropins)
RETISERT (Fluocinolone acetonide)
REVATIO (Sildenafil)
REVESTIVE (Teduglutide)
REVLIMID (Lenalidomide)
REVOLADE (Eltrombopag)
RITUXAN (Rituximab)
RYDAPT (Midostaurine)
SAIZEN (Somatropin)
SAMSCA (Tolvaptan)
SANDOSTATIN (Octreotide)
SANDOSTATIN LR (Octreotide)
SATIVEX (Cannabidiol/Delta-9-tetrahydrocannabinol)
SAXENDA (Liraglutide)
SEROSTIM (Somatropin)
SIGNIFOR (Pasireotide)
SIGNIFOR LAR (Pasireotide)
SILIQ (Brodulamab)
SIMPONI (Golimumab)
SOMAVERT (Pegvisomant)
SOVALDI (Sofosbuvir)
SPINRAZA (Nusinersen)
SPRYCEL (Dasatinib)
STAXYN (Vardenafil)
STELARA (Ustekinumab)
STIVARGA (Regorafenib)
SUTENT (Sunitinib)
SYMDEKO (Tezacaflor/Ivacaftor)
TAFINLAR (Dabrafenib)
TAGRISSO (Osimertinib)
TALTZ (Ixekizumab)
TARCEVA (Erlotinib)
TASIGNA (Nilotinib)
TECFIDERA (Dimethyl Fumarate)
TECHNIVIE (Ombitasvir / Paritaprevir / Ritonavir)
TEGSEDI (Inotersen)
TEMODAL (Temozolomide)
THALOMID (Thalidomide)
THYROGEN (Thyrotropin alfa)
TOCTINO (Alitretinoin)
TRACLEER (Bosentan)
TREMFYA (Guselkumab)
TYKERB (Lapatinib)
TYSABRI (Natalizumab)
UPTRAVI (Selexipag)
VENCLEXTA (Venetoclax)
VIAGRA (Sildenafil)
VICTRELIS (Boceprevir)
VICTRELIS TRIPLE (Boceprevir/ peginterferon alfa-2b/ RBV)
VOLIBRIS (Ambrisentan)
VOSEVI (Sofosbuvir/Velpatasvir/Voxilaprevir)
VOTRIENT (Pazopanib)
XALKORI (Crizotinib)
XELJANZ (Critrate de tofacitinib)
XENICAL (Orlistat)
XEOMIN (IncobotulinumtoxinA)
XIAFLEX (Collagenase Clostridium Histolyticum)
XOLAIR (Omalizumab)
XTANDI (Enzalutamide)
XYREM (Oxybate de sodium)
ZAVESCA (Miglustat)
ZAXINE (Rifaximin)
ZELBORAF (Vemurafenib)
ZEPATIER (Elbasvir / Grazoprevir)
ZOLINZA (Vorinostat)
ZYDELIG (Idelalisib)
ZYKADIA (Ceritinib)
ZYTIGA (Abiraterone acetate)