Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
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Abilify (Nebraska) Prior Authorization Form - Community Plan
Last Modified 08.15.2018
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Actimmune (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.10.2018
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Alzheimer's Drugs (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Androgenic Drugs, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Angiotensin Modulators (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Anthelminitics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Anti-Allergens, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Anti-Migraine Agents, Other (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Anti-Migraine Agents, Triptans (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Anti-Parkinson's Drugs (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Antibiotics, Gastrointestinal (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Antibiotics, Vaginal (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antibiotics, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Anticoagulants (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Anticonvulsants (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antiemetics, Antivertigo Agents (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Antifungals, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antifungals, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antihistamines (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antihypertensives, Sympatholytics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antihyperuricemics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antiparasitics, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antipsoriatics, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antivirals, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Antivirals, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Anxiolytics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Apokyn (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Austedo (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Benlysta (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.07.2018
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Benznidazole (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Berinert (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Beta Blockers, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Bile Salts (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Bladder Relaxant Preparations (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Bone Resorption Suppression Drugs (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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BPH Treatments (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Bronchodilators, Beta Agonist (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Buphenyl (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Calcium Channel Blockers, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Carbaglu (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.14.2018
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Cephalosporins and Related Antibiotics, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Chronic Obstructive Pulmonary Disease (COPD) Agents (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Cialis for BPH (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.08.2018
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Cinryze (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.07.2019
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Colony Stimulating Factors (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Cometriq (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Complera (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.14.2018
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Compound Medications (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Copper Chelating Agents (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Cough and Cold Medications, Opiate Combination (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Cystaran (Nebraska) Prior Authorization Form - Community Plan
Last Modified 08.31.2018
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Cystic Fibrosis Agents, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Cytokine and CAM Antagonists (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Daraprim (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Diuretics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Egrifta (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Elmiron (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Endari (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.14.2018
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Epinephrine, Self Injected (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Erythropoesis Stimulating Proteins (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Evzio (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Exondys 51 (Nebraska) Prior Authorization Form - Community Plan
Last Modified 06.05.2018
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Firazyr (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Fluoroquinolones, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Galafold (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Gattex (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
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Gaucher Disease, Oral Agents (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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GI Motility, Chronic (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Glucocoticoids, Inhaled (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Glucocoticoids, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Gonadotropin-Releasing Hormone Agonists (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Growth Hormone Medications (Nebraska) Prior Authorization Form - Community Plan
Last Modified 08.08.2018
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H.Pylori Treatment (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Haegarda (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Hemlibra (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Hemophilia Treatments (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Hepatitis B Agents (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Hepatitis C Medications (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Histamine II Receptor Blockers (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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HIV Medications (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.08.2018
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HP Acthar Gel (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Human Chorionic Gonadotropin (HCG) (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.08.2018
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Hypoglycemcis, TZD (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Hypoglycemics, Alpha Glucosidase Inhibitors (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Hypoglycemics, Insulin and Related Drugs (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Hypoglycemics, Meglitinides (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Hypoglycemics, Metformins (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Hypoglycemics, SGLT2 (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Hypoglycemics, Sulfonylureas (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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IBS, Diarrhea (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Immunomodulators, Atopic Dermatitis (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Immunomodulators, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Immunosuppressives (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Impavido (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Ingrezza (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Inhaled Antibiotics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 07.24.2018
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Intranasal Rhinitis Drugs (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Iron Chelators (Nebraska) Prior Authorization Form - Community Plan
Last Modified 06.19.2018
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Isotrentinoin [e.g. Amenesteem, Claravis, Myorisan] (Nebraska) Prior Authorization Form - Community Plan
Last Modified 06.25.2018
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Keveyis (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Korlym (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.31.2018
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Kuvan (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Lenvima (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Leukotriene Modifiers (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Lidoderm Patch (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.04.2018
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Lipotropics - Other (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Lipotropics - Statins (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Long-Acting Injectibles (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Lyrica (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Lysteda (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
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Macrolides and Ketolides - Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Makena (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.09.2018
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Mepron (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.12.2018
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Methotrexate (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Mirvaso (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
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Movement Disorder Medications (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Mulpleta (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
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Multaq (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Multiple Sclerosis (MS) Medications (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.04.2018
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Myalept (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Mytesi (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Nitrofuran Derivatives (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Nityr (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.10.2018
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Nonsteroidal Anti-Inflammatory Drugs (NSAID) (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Northera (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Nuedexta (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Nuplazid (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
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Oncology Agents, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.07.2018
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Ophthalmic Antibiotic - Steroid Combinations (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Ophthalmics - Allergic Conjuctivitis (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Ophthalmics - Anti-Inflammatories (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Ophthalmics - Antibiotics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Ophthalmics - Glaucoma (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Opiate Dependence Treatments (Nebraska) - [Suboxone, Bunavail, Buprenorphine, Buprenorphine/Naloxone and Zubsolv] - Prior Authorization Form - Community Plan
Last Modified 05.09.2018
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Orfadin (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.10.2018
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Otic - Anti-Infectives and Anesthetics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Otic - Antibiotics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Palynziq (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.14.2019
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Pancreatic Enzymes (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Penicillins (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018
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Phosphate Binders (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Platelet Aggregate Inhibitors (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Prevymis (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.10.2018
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Procysbi (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.10.2018
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Progesterone, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.10.2018
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Promacta (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Psychotropic Requests in Children (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Pulmonary Arterial Hypertension Agents - Oral and Inhaled (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Pulmozyme (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Ranexa (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
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Ravicti (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Re-Review Reconsideration Request Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Rectiv (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
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Relistor, Injection (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.09.2018
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Rhofade (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
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Ruconest (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Sabril (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Samsca (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Sedative Hypnotics (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Sensipar (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
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Short-Acting Opioid Products (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.09.2018
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Signifor (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Sinus Node Inhibitors (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Skeletal Muscle Relaxants (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Somavert (Nebraska) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Stelara (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Steroids, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.01.2018
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Stimulants and Related ADHD Drugs (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Synribo (Nebraska) Prior Authorization Form - Community Plan
Last Modified 06.25.2018
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Tagrisso (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Test Strips (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.07.2018
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Tetracyclines (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Thyroid Hormone Medications (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Ulcerative Colitis (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Valchlor (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
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Vasodilators, Coronary (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Vecamyl (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Veltassa (Nebraska) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
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Venclexta (Nebraska) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Xermelo (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.12.2018
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Xuriden (Nebraska) Prior Authorization Form - Community Plan
Last Modified 10.12.2018
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Xyrem (Nebraska) Prior Authorization Form - Community Plan
Last Modified 04.26.2018