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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Actimmune (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.10.2018
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Alzheimer's Agents (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Androgenic Drugs, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.07.2019
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Angiotensin Modulators (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Anthelminitics (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Anti-Allergens, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Anti-Migraine Agents, Other (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Anti-Migraine Agents, Triptans (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Anti-Parkinson's Drugs, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 07.08.2019
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Antibiotics, Gastrointestinal (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Antibiotics, Inhaled (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.22.2019
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Antibiotics, Vaginal (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Antibiotics, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Anticoagulants (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.11.2019
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Anticonvulsants (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.07.2019
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Antiemetics, Antivertigo Agents (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Antifungals, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.11.2019
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Antifungals, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Antihistamines, Minimally Sedating (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.20.2019
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Antihypertensives, Sympatholytics (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Antihyperuricemics (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.11.2019
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Antiparasitics, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Antipsoriatics, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Antipsychotics (Nebraska) Prior Authorization Form - Community Plan
Last Published 09.24.2019
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Antivirals, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Antivirals, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Anxiolytics (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Apokyn (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Benznidazole (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Berinert (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Beta Blockers, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Bile Salts (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Bladder Relaxant Preparations (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Bone Resorption Suppression Drugs (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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BPH Treatments (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Bronchodilators, Beta Agonist (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Buphenyl (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.11.2019
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Cablivi (Nebraska) Prior Authorization Form - Community Plan
Last Published 09.25.2019
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Calcium Channel Blocker, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Cephalosporins and Related Antibiotics, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.11.2019
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Chronic Obstructive Pulmonary Disease (COPD) Agents (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Cinryze (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Colony Stimulating Factors (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Compound Medications (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Copper Chelating Agents (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Cough and Cold Medications, Opiate Combination (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.10.2020
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Cystaran (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Cystic Fibrosis Agents, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Cytokine and CAM Antagonists (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Daraprim (Nebraska) Prior Authorization Form - Community
Last Published 11.07.2019
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Daurismo (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.25.2019
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Diuretics (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Doptelet (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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Endari (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.01.2019
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Enzyme Replacement, Gauchers Disease (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Erythropoiesis Stimulating Proteins (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Exondys 51 (Nebraska) Prior Authorization Form - Community Plan
Last Published 09.24.2019
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Firazyr (Nebraska) Prior Authorization Form - Community Plan
Last Published 05.03.2018
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Firdapse (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.10.2020
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Fluoroquinolones, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Galafold (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.11.2019
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Gattex (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.03.2019
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GI Motility, Chronic (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Glucocorticoids, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Glucocoticoids, Inhaled (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.30.2018
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Gonadotropin-Releasing Hormone Agonists (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.30.2018
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Haegarda (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Hemlibra (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Hemophilia Treatments (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Hepatitis B Agents (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Hepatitis C Medications (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.04.2019
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HIV Medications (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.29.2019
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HP Acthar Gel (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.07.2019
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Hypoglycemics, Incretin Mimetics / Enhancers (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Hypoglycemics, SGLT2 (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Ilaris (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Immunomodulators, Atopic Dermatitis (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Immunomodulators, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.29.2020
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Immunosuppressives (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Insulin Pen Needles and Syringes (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Intranasal Rhinitis Drugs (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Lincosamides / Oxazolidinones / Streptogramins (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.29.2019
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Lipotropics - Statins (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Lokelma / Veltassa (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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Lyrica (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Lysteda (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.04.2019
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Makena (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Mepron (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.12.2018
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Mirvaso (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.02.2019
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Mozobil (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Mulpleta (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.10.2019
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Multiple Sclerosis (MS) Medications (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.31.2019
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Natpara (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Nityr (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.10.2018
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Noctiva & Nocdurna (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.01.2019
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Nuplazid (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.02.2019
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Oncology Agents, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Ophthalmic Antibiotic - Steroid Combinations (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Ophthalmics, Anti-Inflammatory Immunomodulators (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Ophthalmics, Antibiotics (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Ophthalmics, Glaucoma (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Opiate Dependence Treatments (Nebraska) - [Suboxone, Bunavail, Buprenorphine, Buprenorphine/Naloxone and Zubsolv] - Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Opioid Products (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.24.2020
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Orfadin (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.10.2018
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Orilissa (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Osphena (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.04.2019
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Oxervate (Nebraska) Prior Authorization Form - Community Plan
Last Published 04.16.2019
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Palynziq (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.14.2019
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Panretin (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Pediatric Vitamin Preparations (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.01.2019
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Phosphate Binders (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.28.2018
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Platelet Aggregation Inhibitors (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Prenatal Vitamins (Nebraska) Prior Authorization Form - Community Plan
Last Published 02.01.2019
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Prevymis (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Procysbi (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.10.2018
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Progesterone, Oral (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.10.2018
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Promacta (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Proton Pump Inhibitors (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Pulmonary Arterial Hypertension Agents - Oral and Inhaled (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Ranexa (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.02.2019
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Rectiv (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.03.2019
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Regranex (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Rhofade (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.02.2019
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Ruzurgi (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Sabril (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Samsca (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.11.2019
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Sandostatin (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.22.2019
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Sedative Hypnotics (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Sensipar (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.02.2019
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Signifor (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.11.2019
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Skeletal Muscle Relaxants (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Somavert (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.28.2018
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Spravato (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.22.2019
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Steroids, Topical (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Stimulants and Related ADHD Products (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.04.2019
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Strensiq (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Takhzyro (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Tavalisse (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Tegsedi (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.04.2019
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Tetracyclines (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Thyroid Hormone Medications (Nebraska) Prior Authorization Form - Community Plan
Last Published 06.03.2019
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Ulcerative Colitis (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Valchlor (Nebraska) Prior Authorization Form - Community Plan
Last Published 01.10.2019
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Vasodilators, Coronary (Nebraska) Prior Authorization Form - Community Plan
Last Published 11.16.2019
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Vitrakvi (Nebraska) Prior Authorization Form - Community Plan
Last Published 03.25.2019
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Xermelo (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.12.2018
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Xolair (Nebraska) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Xuriden (Nebraska) Prior Authorization Form - Community Plan
Last Published 10.12.2018