Medicare Part D Medications That Require Prior Authorization


If you have prescribed or are prescribing one of the drugs below for a Medi-Pak Rx® member, you can click on the name of the medication and print and complete the attached form to fax to CVS/Caremark at 1-888-836-0730. If you have questions regarding the prior authorization process, please call 1-800-294-5979.


  • Accuneb solution
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  • Forteo
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  • Oxycontin (post limit)
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  • Acetylcysteine inhalation solution
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  • Frova (post limit)
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  • Peg-Intron
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  • Actiq (post limit)
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  • Granisetron, Ondansetron oral
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  • Pegasys
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  • Adderall XR
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  • Growth Hormone
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  • Pentamidine solution
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  • Afinitor
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  • Hepatitis B Vaccine
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  • Perforomist solution
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  • Albuterol Sulfate solution
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  • Humira
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  • Procrit and Epogen
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  • Amerge (post limit)
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  • Imitrex injection (post limit)
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  • Prograf
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  • Amphetamine-Dextroamphetamine
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  • Imitrex nasal spray (post limit)
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  • Protopic (step therapy)
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  • Androderm
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  • Imitrex tablets (post limit)
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  • Provigil
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  • Androgel
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  • Immune Globulins
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  • Pulmicort Respules
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  • Anzemet
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  • Increlex
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  • Pulmozyme solution
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  • Aranesp
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  • Infergen
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  • Rapamune
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  • Avinza ER (post limit)
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  • Iplex
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  • Rebetol oral solution
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  • Axert (post limit)
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  • Ipratropium Bromide solution
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  • Regranex
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  • Azathioprine
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  • Ipratropium-Albuterol solution
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  • Relpax (post limit)
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  • Brovana solution
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  • Itraconazole capsules
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  • Remicade
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  • Butorphanol Nasal-Systemic (post limit)
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  • Kadian ER (post limit)
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  • Revatio
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  • Celebrex
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  • Kineret
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  • Revlimid
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  • Cellcept
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  • Lamisil oral granules
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  • Ribavirin
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  • Cesamet (post limit)
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  • Leukine
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  • Sandimmune
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  • Chorionic Gonadotropin
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  • Lipids, Amino Acids Infusion
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  • Sandostatin LAR
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  • Cimzia
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  • Liquadd
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  • Serostim
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  • Colistimethate solution
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  • Marinol (post limit)
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  • Somatuline
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  • Cromolyn Sodium solution
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  • Maxalt (post limit)
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  • Somavert
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  • Cyclophosphamide
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  • Metaproterenol solution
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  • Striant
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  • Cyclosporine
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  • Methadone, Methadose (post limit)
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  • Terbinafine tablets
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  • Desoxyn
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  • Methylphenidate
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  • Testim
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  • Dextroamphetamine
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  • Morphine Sulfate ER (post limit)
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  • Tetanus injection
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  • Dextrostat
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  • MS Contin ER (post limit)
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  • Thalomid
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  • Differin
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  • Myfortic
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  • TOBI nebulizer solution
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  • Dolophine (post limit)
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  • Neoral
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  • Tretinoin products
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  • Duoneb solution
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  • Neulasta
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  • Trexall
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  • Duragesic (post limit)
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  • Neumega
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  • Treximet (post limit)
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  • Elidel (step therapy)
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  • Neupogen
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  • Ventavis solution
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  • Emend 40mg (post limit)
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  • Octreotide
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  • Vyvanse
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  • Emend 80mg or 125mg (post limit)
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  • Opana ER (post limit)
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  • Xenazine
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  • Enbrel
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  • Oramorph ER (post limit)
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  • Xopenex solution
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  • Fentanyl oral (post limit)
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  • Orencia
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  • Zomig (post limit)
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  • Fentanyl patch (post limit)
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  • Oxandrolone
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  • Zorbtive
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  • Fentora (post limit)
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