Medicare Part D Medications - Arkansas Blue Cross and Blue Shield

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

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Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue
Shield Association and is licensed to offer health plans in all 75 counties of Arkansas.
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