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ADHD Products (Colorado) Prior Authorization Form - Community Plan
Last Published 02.11.2021
"Adderall XR, Adderall, Adhansia XR, Adzenys ER, Adzenys XR-ODT, amphetamine ER susp, amphetamine, amphetamine/dextroamphetamine ER, amphetamine/dextroamphetamine, Aptensio XR, atomoxetine, clonidine ER, Concerta, Cotempla XR-ODT, Daytrana, Desoxyn, Dexedrine, dexmethylphenidate ER, dexmethylphenidate, dextroamphetamine ER, dextroamphetamine soln, dextroamphetamine, Dyanavel XR, Evekeo ODT, Evekeo, Focalin XR, Focalin, guanfacine ER, Intuniv, Jornay PM, Kapvay, Metadate ER, methamphetamine, Methylin, methylphenidate cap, methylphenidate ER (CD), methylphenidate ER (LA), methylphenidate ER OSM, methylphenidate ER tab, methylphenidate soln, methylphenidate, Mydayis, Procentra, Quillichew ER, Quillivant XR, Relexxii, Ritalin LA, Ritalin, Strattera, Vyvanse, Zenzedi",
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Antipsychotics (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Abilify Maintena, Abilify MyCite, Abilify tabs, aripiprazole ODT, aripiprazole oral solution, aripiprazole tablets, aripiprazole tabs, Aristada, Caplyta , chlorpromazine injection, chlorpromazine tablets, clozapine 200 mg tablet, clozapine ODT, clozapine tablets, clozapine, Clozaril 200mg tab, Clozaril, Fanapt, Fanapt, Fazaclo, fluphenazine, Geodon, haloperidol decanoate injection, haloperidol injection, haloperidol oral concentrate, haloperidol tablets, Invega Sustenna, Invega Trinza, Invega, Latuda, loxapine, molindone tablets, molindone, olanzapine ODT, olanzapine tablets, olanzapine, paliperidone ER, perphenazine, Perseris, pimozide, quetiapine ER, quetiapine, Rexulti, Risperdal Consta, Risperdal oral solution, Risperdal tabs, risperidone ODT, risperidone oral solution, risperidone solution, risperidone tablets, risperidone tabs, Saphris, Secuado, Seroquel XR, Seroquel, thioridazine, thiothixene, trifluoperazine, Versacloz suspension, Versacloz, Vraylar, ziprasidone, Zyprexa Zydis, Zyprexa",
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Belbuca / Butrans (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Belbuca, Butrans, buprenorphine patch ",
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Benzodiazepines (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Xanax, alprazolam, Xanax XR, alprazolam ER, alprazolam intensol, alprazolam ODT, chlordiazepoxide, Tranxene T, chlorazepate, Valium, diazepam, Ativan, lorazepam, oxazepam ",
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Calcitonin Gene-Related Peptide [CGRP] Antagonists (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Aimovig, Ajovy, Emgality",
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Celebrex (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Celebrex, Celecoxib",
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DPP-4 Inhibitors (Colorado)Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Januvia, Janumet, Janumet XR, Onglyza, Kombiglyze XR, Tradjenta, Jentadueto, Jentadueto XR, Nesina, alogliptin, Kazano, alogliptin/metformin, Oseni, alogliptin/pioglitazone",
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Dry Eye Disease (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Cequa, Restasis, Restasis Multidose, Xiidra ",
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Dupixent (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Dupixent, dupilumab",
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Glucagon-like peptide-1 [GLP-1] Agonists (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Bydureon, Bydureon BCise, Byetta, Ozempic , Rybelsus, Victoza, Adlyxin, Trulicity ",
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Gonadotropin-Releasing Hormone Agents (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"leuprolide acetate, Lupron Depot Ped, Triptodur, Lupaneta Pack, Lupron Depot",
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Growth Hormone Medications (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Genotropin, Genotropin Miniquick, Humatrope, Norditropin, Norditropin Flexpro, Nutropin AQ NuSpin, Omnitrope, Saizen, Saizen Click Easy, Zomacton, Zorbitive, Serostim, Somatropin, Mecasermin, Increlex",
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Hepatitis C Medications (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier",
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Humira (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Humira, adalimumab",
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Ingrezza (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Ingrezza, valbenazine",
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Inhaled Corticosteroid / Long Acting Beta Agonist Combinations (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"fluticasone propionate/salmeterol diskus, Wixela Inhub, Advair HFA, Dulera, AirDuo, Symbicort, budesonide/formoterol, Advair Diskus, Breo Ellipta ",
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Inhaled Corticosteroids (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Flovent HFA, Alvesco, Asmanex Twisthaler, Flovent Diskus, Pulmicort Flexhaler, Asmanex HFA ",
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Omega [Lovaza, Vascepa] (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Lovaza, omega-3-acid ethyl esters, Vascepa ",
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Opioid Products (Colorado) Prior Authorization Form - Community Plan
Last Published 11.09.2020
"Arymo, Conzip, Dolophine, Duragesic, Embeda, Exalgo, fentanyl patch, hydrocodone ER, hydromorphone ER, Hysingla ER, Kadian, methadone, Methadose, Morphabond ER, morphine sulfate ER, MS Contin, Nucynta ER, oxycodone ER, oxymorphone ER, Oxycontin, tramadol ER, Xtampza ER, Zohydro ER, acetaminophen w/codeine, acetaminophen-caffeine-dihydrocodeine, Apadaz, Ascomp/Codeine, belladonna alkaloids & opium suppositories, benzhydrocodone-acetaminophen, butalbital-acetaminophen-caffeine w/codeine, butalbital-aspirin-caffeine w/codeine, butorphanol nasal spray, carisoprodol-aspirin-codeine, codeine sulfate, Dilaudid, Dvorah, Endocet, Fioricet/Codeine, Fiorinal/Codeine, Fortigan, hydrocodone-acetaminophen, hydrocodone-ibuprofen, hydromorphone, levorphanol, Lorcet HD, Lorcet Plus, Lorcet, Lortab, meperidine, morphine, Nalocet, Norco, Nucynta, Opana, opium tincture, Oxaydo, oxycodone, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, oxymorphone, pentazocine w/naloxone, Percocet, Primlev, Roxicodone, Synapryn, tramadol, tramadol-acetaminophen, Trezix, Tylenol w/Codeine, Ultracet, Ultram, Vicodin HP, Xodol",
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Praluent (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Praluent, alirocumab",
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Prior Authorization Request Form for Rocky Mountain Health Plan
Last Published 10.27.2020
,
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Repatha (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Repatha, evolocumab, Repatha Pushtronex, Repatha SureClick",
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SGLT-2 Inhibitors (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Steglatro, Segluromet, Jardiance, Invokana, Synjardy, Synjardy XR, Invokamet, Invokamet XR, Xigduo XR, Farxiga",
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Suboxone / Subutex (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Zubsolv, Bunavail, Suboxone sublingual film , buprenorphine/naloxone sublingual film, buprenorphine/naloxone sublingual tablet, buprenorphine sublingual tablet ",
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Synagis (Colorado) Prior Authorization Form - Community Plan
Last Published 11.03.2020
Synagis, palivizumab,
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Test Strips (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
,
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Topical Nonsteroidal Anti-Inflammatory Drugs [NSAIDs] (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Flector Patch, diclofenac epolamine patch, Pennsaid, diclofenac sodium soln, Voltaren gel, diclofenac topical gel",
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Topical Retinoids (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Aklief cream, Altreno, Atralin, tretinoin gel, Avita cream/gel, Differin cream, adapalene cream, Differin gel, adapalene gel, Differin lotion, adapalene lotion, Epiduo, adapalene/benzoyl peroxide, Epiduo Forte, Fabior foam, Retin-A cream, Retin-A gel, tretinoin gel, Retin-A Micro, tretinoin microspheres, Tazorac cream, tazarotene cream, Tazorac gel, tretinoin cream ",
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Xarelto (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Xarelto, rivaroxaban, Xarelto Starter Pack",
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Xifaxan (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Xifaxan, rifaximin",
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Xolair (Colorado) Prior Authorization Form - Community Plan
Last Published 11.02.2020
"Xiolair, omalizumab",