HealthChoice Medicare Supplement Plans With and Without
Part D Medications Requiring Prior Authorization
The medications listed on this page
may require prior authorization. This list is not all inclusive and is subject to change.
See bottom of page for contact information.
Some medications listed in these categories are non-formulary. If a prior authorization is
granted, the medication will be covered at the non-Preferred copay. Use the
Comprehensive Formulary link to verify if the medication is a covered drug.
Use the links below for easy access to categories of Prior Authorization
medications.
Anabolic Steroids
- Anadrol-50 (oxymetholone tablets)
- Deca-Durabolin
- Kabolin (nandrolone decanoate injection)
- Oxandrin (oxandrolone tablets)
- Winstrol (stanozolol tablets)
Androgens
- Androderm (testosterone transdermal system)
- Androgel
- Android (methyltestosterone tablets)
- First-Testosterone (testosterone propionate ointment)
- Halotestin (fluoxymesterone tablets)
- Oreton
- Methitest
- Methyltestosterone
- Testim (testosterone gel)
- Testoderm Patch
- Testoderm TTS
- Testred
- Virilon (methyltestosterone capsules)
Androgens – Injectable
- Andro-Cyp
- Andro LA
- andropository
- Delatestryl (testosterone enantha)
- depotest
- Depo-Testosterone (testosterone cypiona)
- Tesamone (testosterone)
- Testro (testosterone aqueous injection)
- Testro-LA (testosterone enanthate injection)
- Virilon (methyltestosterone injection)
- Virilon IM (testosterone cypionate injection)
Antiemetics
- Anzemet (dolasetron)
- Emend (aprepitant)
- Kytril (granisetron)
- Zofran (ondansetron)
Anti-Infective Agents
- Vfend (voriconazole)
- Zyvox (linezolid)
Anti-Infective Inhalant Agents
- Tobi (tobramycin solution for inhalation)
Anti-viral Agents
- Relenza (zanamivir)
- Tamiflu osteltamivir
CNS Stimulants (Prior authorization required for
age 21 and older)
- Adderall (amphet ASP/amphet D)
- Adderall XR (amphetamine/dextroamphetamine combination)
- Concerta (methylphenidate)
- Dexedrine (destroamphetamine)
- Dextrostat (dextroamphetamine)
- Desoxyn
- Desoxyn Graduate (methamphetamine)
- Focalin (dexmethylphenidate)
- Ritalin (methyphenidate HCL)
- Ritalin LA (methylphenidate)
- Ritalin SR (methylphenidate)
- Metadate CD (methylphenidate)
- Methylin ER (methylphenidate)
Colony Stimulating Factors
- G-CSF (granulocyte colony-stimulating factor
- GM-CSF (granulocyte-macrophage colony-stimulating factor)
- Leukine (sargramostim)
- Neulasta (pegfilgrastim)
- Neupogen (filgrastim)
COX-II Inhibitors
Erythroid Stimulants
- Aranesp (darbepoetin alfa injection)
- Epogen
- Procrit (epoetin alfa injection)
Erectile Dysfunction / Impotence Agents
These medications are specifically excluded unless you have had radical retropubic
prostatectomy surgery.
- Caverject
- Cialis (tadalafil)
- Edex (alprostadil injection)
- Levitra (vardenafil)
- Muse (alprostadil urethral inserts)
- Viagra (sildenafil tablets)
Gastrointestinal Agents
Growth Hormones
- Depot (somatrem)
- Genotropin
- Genotropin Miniquick
- Geref (somatropin)
- Humatrope
- Norditropin
- Nutropin
- Nutropin AQ
- Protropin
- Saizen (somatropin)
- Zorbtive (somatropin)
Growth Hormone Receptor Antagonists
Biological Response Modulator - Human Growth Factors
Immunosuppressant Agents
- Cellcept (mycophenolate)
- Cytoxam (cyclophosphamide)
- Imuran (azathioprine)
- Myfortic (mycophenolic acid)
- Neoral (cyclophosphamide)
- Orthoclone OKT3 (muromonab-CD3)
- Prograf
- Protopic (tacrolimus)
- Rapamune (sirolimus)
- (prednisone)
- (prednisolone)
- Sandimmune (cyclosporine)
- Thymoglobulin (antithymocyte globulin)
- Zenapax (daclizumab)
Injectable Medications and Other Miscellaneous Treatments
- Aldurazyme (laronidase)
- Ambisome (amphotericin B)
- Anxemet (dolasetron)
- Avelox (moxifloxacin)
- (BCG vaccine)
- Camptosar (irinotecan)
- Cerezyme (imiglucerase)
- Cipro (ciprofloxacin)
- Cytovene (ganciclovir)
- Dobutrex (dobutamine)
- (dopamine)
- Eligard (leuprolide)
- Fabrazyme (agalsidase beta)
- Faslodex (fulvestrant)
- Flagyl (metronidazole)
- Floxin (ofloxacin)
- Fludara (fludarabine)
- Foscavir (foscarnet)
- Ganite (gallium nitrate)
- Geodon (ziprasidone)
- Haldol (haloperidol decanoate)
- Kemstro (baclofen)
- Kytril (granisetron)
- Leustat (cladribine)
- Nebupent (pentamidine)
- Nexium (esomeprazole)
- Nitrostat (nitroglycerin)
- Platinol (cisplatin)
- Primacor (milrinone)
- Prolastin (alpha-1 proteinase inhibitor)
- Proleukin (aldesleukin)
- Protonix (pantoprazole)
- Risperdal Consta (risperidone)
- Trilafon (perphenazine)
- Trisenox (arsenic)
- Uromitexan (mesna)
- Vfend (voriconazole)
- Vibramycin (doxycycline)
- Vitrasert Implant (ganciclovir)
- Zithromax (azithromycin)
- Zofran (ondasetron)
- Zoladex Implant (goserelin)
- Zovirax (acyclovir)
Intravenous Immune Globulins
- Gamimune N
- Gammagard
- Gammar-IV
- Iveegam (immuneglobin, gamm)
- Sandoglobulin
- Venoglobulin
Nebulized Drugs
- Accuneb (albuterol sulfate)
- Alupent (metaproterenol)
- Atrovent (ipratropium bromide)
- Brethine (terbutaline sulfate)
- Crolom (cromolyn sodium)
- Decadron (dexamethasone)
- DuoNeb (albuterol sulfate/ipratropium bromide)
- Maxidex (dexamethasone)
- Mucosil Mucomyst (acetylcysteine)
- Mucomyst-10 (acetylcysteine)
- NebuPent (pentamidine isethionate)
- Pulmicort (budesonide)
- Robinul (glycopyrrolate)
- Tornalate (bitolterol)
- Xopenex (isoetharine, levosalbutamol hydrochloride)
Osteoporosis Therapy
Respiratory Agents
- Pulmozyme (recombinant dornase alfa inhalation solution)
- Synagis (palivizumab)
- Xolair (omalizumab)
- Xoponex (levalbuterol inhalation solution)
Topical Retinoids
& Miscellaneous Dermatologicals (Prior authorization required for age 23 and older)
To request prior authorization for these medications, please have your
physician contact Medco Health at 1-800-753-2851, Monday through Friday (7AM-8PM CST).
TDD users call
1-800-825-1230.
Last Modified on: 1/23/2009 10:15:01 AM
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