Drug Benefit Exception (Prior Authorization) Forms for the Non-RIte Care Pharmacy Benefit

Advair/Symbicort
Aldara
Angiotensin Receptor Blockers

Anorexiant

Baraclude

Botox
[Provider office must buy the drug and bill Neighborhood]

Byetta

Cimzia

Copegus

Elidel-Protopic

Emend

Enbrel

Epoetin (Chemo Induced)

Epoetin (Non-Chemo Induced)

Flomax and Avodart

Growth Hormone (Omnitrope)

Humira

Hyaluronate Products (ex. Synvisc, Hyalgan)

Infergen
Insulin Pen

Intron-A

Invega Sustenna

Lamisil

Lupron

Lyrica

Nutritional Supplement (ex. Boost, Ensure)
[Do not submit form if the patient is under 5 years old or pregnant or breast feeding; refer patient to WIC for coverage of Nutritional Supplement]

Orencia
Oxycontin

Paroxetine

Peg-Intron

Pegasys form

Pegasys guide
Propoxyphene containing products
Proton Pump Inhibitors
Proton Pump Inhibitor - Plavix Interaction

Protopic
Provigil

Rebetol

Remicade

Restasis

Retin A

Risperdal Consta

Roferon-A

Singulair (Covered only for asthma)

Sporanox
Statins

Suboxone

Subutex

Symlin

Triptans

Tysabri

Ventavis

Weight Loss renewal

Xolair

Zyprexa Relprevv

Zyvox

All Others