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    Pharmacy Prior Authorization

    Drug Prior Authorization

    Prior authorization requests must be submitted electronically through the CareFirst Provider Portal for all drugs requiring prior authorization.

    If you are already using the CareFirst Provider Portal, login at www.carefirst.com/providerlogin, and click on the Prior Auth/Notifications tab to begin your request. If you are not yet registered to use the Provider Portal, you can do so at www.carefirst.com/carefirstdirect.

    Questions?

    If you are experiencing technical difficulties with the Provider Portal, please contact the CareFirst Help Desk at 877-526-8390.

    For all other questions regarding the submission of your request, please contact CVS Caremark:

    For more information on submitting drug prior authorization electronically, register for an upcoming webinar, view our training video or download the user guide.

    Jump To:

    #

    Drug Name
    Drug Criteria
    5H1 Agonsit Post QL PA® 5H1 Agonsit Post QL PA®

    A

    Drug Name
    Drug Criteria
    Abilify® Abilify®
    Abraxane® Abraxane®
    Abstral® Abstral®
    Accu-Check Aviva Plus Test Strips Accu-Check Aviva Plus Test Strips Policy
    Actemra IV® Actemra IV®Policy
    Actemra SQ® Actemra SQ® Policy
    Acthar® Acthar® Policy
    Actimmune® Actimmune® Policy
    Actiq® Actiq® Policy
    Actos Actos®
    Adagen® Adagen® Policy
    Adcirca® Adcirca® Policy
    Adderall XR® Adderall XR®
    Adempas® Adempas® Policy
    Adrenaclick® Adrenaclick®
    Advate® Advate® Policy
    Advicor® Advicor®
    Aerospan® Aerospan®
    Afinitor® Afinitor® Policy
    Aldurazyme® Aldurazyme® Policy
    Alecensa® Alecensa® Policy
    Alferon® Alferon® Policy
    Alimta® Alimta® Policy
    Alphanate® Alphanate® Policy
    Alphanine SD® Alphanine SD® Policy
    Alprolix® Alprolix® Policy
    Alsuma® Alsuma® Policy
    Altoprev® Altoprev®
    Alvesco® Alvesco®
    Amitiza® Amitiza®
    Ampyra® Ampyra® Policy
    Amrix® Amrix®
    Androgel® Androgel®
    Apexicon E PA-ECX® Apexicon E PA-ECX®
    Apidra FA-EXC® Apidra®
    Apokyn® Apokyn® Policy
    Aralast NP® Aralast NP® Policy
    Aranesp® Aranesp® Policy
    Arcalyst® Arcalyst® Policy
    Arthrotec® Arthrotec®
    Asacol-HD® Asacol®
    Atacand® Atacand®
    Atacand HCT® Atacand HCT®
    Atralin® Atralin® Policy
    Aubagio® Aubagio® Policy
    Avastin® Avastin® Policy
    Avita® Avita® Policy
    Avonex® Avonex® Policy
    Azacitidine® Azacitidine® Policy

    B

    Drug NameDrug Criteria
    Bayer Contour Test Strips® Bayer Contour Test Strips®
    Bebulin VH® Bebulin VH®
    Beconase AQ Policy® Beconase AQ Policy®
    Bendeka® Bendeka®
    Benefix® Benefix®
    Benlysta® Benlysta®
    Berinert® Berinert®
    Betaseron® Betaseron®
    Bethkis® Bethkis®
    Bexarotene® Bexarotene®
    Bivigam® Bivigam®
    Bosulif® Bosulif®
    Botox® Botox®
    Bravelle® Bravelle®
    Breeze 2 Test Strips and Kits4® Breeze 2 Test Strips and Kits4®
    Buphenyl® Buphenyl®
    Butophanol® Butophanol®
    Bydureon® Bydureon®
    Byetta® Byetta®

    C

    Drug NameDrug Criteria
    Capecitabine® Capecitabine®
    Caprelsa® Caprelsa®
    Carac® Carac®
    Carbaglu® Carbaglu®
    Cardizem® Cardizem®
    Cardizem CD® Cardizem CD®
    Cardizem LA® Cardizem LA®
    Carimune NF® Carimune NF®
    Cayston® Cayston®
    Cerdelga® Cerdelga®
    Cerezyme® Cerezyme®
    Cetrotide® Cetrotide®
    Cholbam® Cholbam®
    Cimzia® Cimzia®
    Cinryze® Cinryze®
    Clobetasol Spray® Clobetasol Spray®
    Clobex Spray® Clobex Spray®
    Cometriq® Cometriq®
    Compounded Drug Products® Compounded Drug Products®
    Copaxone® Copaxone®
    Copegus® Copegus®
    Corifact® Corifact®
    Cosentyx® Cosentyx®
    Cotellic® Cotellic®
    Cymbalta® Cymbalta®
    Cystagon® Cystagon®
    Cystaran® Cystaran®
    Cytogam® Cytogam®

    D

    Drug Name
    Drug Criteria
    Daklinza® Daklinza®
    Delzicol® Delzicol®
    Detrol LA® Detrol LA®
    Diovan HCT Policy® Diovan HCT Policy®
    Docefrez® Docefrez®
    Duexis® Duexis®
    Dymista® Dymista®
    Dysport® Dysport®

    E

    Drug Name
    Drug Criteria
    Edarbi® Edarbi®
    Edarbyclor® Edarbyclor®
    Egrifta® Egrifta®
    Elaprase® Elaprase®
    Eleyso® Eleyso®
    Eligard® Eligard®
    Elocate® Elocate®
    Eloxatin® Eloxatin®
    Enbrel® Enbrel®
    Entesto® Entesto®
    Entyvio® Entyvio®
    Epogen® Epogen®
    Epoprostenol® Epoprostenol®
    Erbitux® Erbitux®
    Erivedge® Erivedge®
    Esbriet® Esbriet®
    Exflexxa Policy® Exflexxa Policy®
    Exforge® Exforge®
    Exforge HCT® Exforge HCT®
    Exjade® Exjade®
    Extavia® Extavia®
    Eylea® Eylea®

    F

    Drug Name
    Drug Criteria
    Fabior® Fabior®
    Fanrazyme® Fanrazyme®
    Farydak® Farydak®
    Feiba NF® Feiba NF®
    Feiba VH® Feiba VH®
    Fentanyl Citrate Oral TRA® Fentanyl Citrate Oral TRA®
    Fentora® Fentora®
    Ferriprox® Ferriprox®
    Firazyr® Firazyr®
    Firmagon® Firmagon®
    Flebogamma® Flebogamma®
    Flolan® Flolan®
    Fluorouracil Cream 0.5%® Fluorouracil Cream 0.5%®
    Follistim AQ® Follistim AQ®
    Fortamet® Fortamet®
    Forteo® Forteo®
    Fortesta® Fortesta®
    Fosrenol® Fosrenol®
    Freestyle Test Strips® Freestyle Test Strips®
    Frova Post Limit® Frova Post Limit®
    Fuzeon® Fuzeon®

    G

    Drug Name
    Drug Criteria
    Gamastan S/D® Gamastan S/D®
    Gammagard® Gammagard®
    Gammaked® Gammaked®
    Gammaplex® Gammaplex®
    Gamunex® Gamunex®
    Ganirelix Acetate® Ganirelix Acetate®
    Gattex® Gattex®
    Gel-One® Gel-One®
    Gemzar® Gemzar®
    Genotropin® Genotropin®
    Gilenya® Gilenya®
    Gilotrif® Gilotrif®
    Glassia® Glassia®
    Glatopa® Glatopa®
    Gleevec® Gleevec®
    Glumetza® Glumetza®
    Gonal-F® Gonal-F®
    Gonal-F RFF® Gonal-F RFF®
    Granix® Granix®

    H

    Drug Name
    Drug Criteria
    Harvoni® Harvoni®
    Hecoria® Hecoria®
    Helixate FS® Helixate FS®
    Hemofil M® Hemofil M®
    Herceptin® Herceptin®
    Hetlioz® Hetlioz®
    Hizentra® Hizentra®
    Humalog® Humalog®
    Humalog Mix 50/60® Humalog Mix 50/60®
    Humalog Mix 75/25® Humalog Mix 75/25®
    Humate-P® Humate-P®
    Humatrope® Humatrope®
    Humira® Humira®
    Humulin 70/30 2® Humulin 70/30®
    Humulin N 2® Humulin N 2®
    Humulin R 2® HUmulin R 2®
    Hyalgan® Hyalgan®
    Hycamtin® Hycamtin®
    HyQvia® HyQvia® Policy

    I

    Drug Name
    Drug Criteria
    Ibrance® Ibrance®
    Iclusig® Iclusig®
    Ilaris® Ilaris®
    Imbruvica® Imbruvica®
    Increlex® Increlex®
    Incruse Ellipta® Incruse Ellipta®
    Infelctra® Infelctra® Policy
    Influenza Treatment Post QL PA® Influenza Treatment Post QL PA®
    Inlyta® Inlyta®
    Intermezzo® Intermezzo®
    Intron A® Intron A®
    Intuniv® Intuniv®
    Invokamet® Invokamet®
    Invokana® Invokana®
    Iressa® Iressa®

    J

    Drug Name
    Drug Criteria
    Jadenu® Jadenu®
    Jakafi® Jakafi®
    Jalyn® Jalyn®
    Juxtapid® Juxtapid®

    K

    Drug Name
    Drug Criteria
    Kadcyla® Kadcyla®
    Kalbitor® Kalbitor®
    Kalydeco® Kalydeco®
    Kazano® Kazano®
    Kineret® Kineret®
    Kitabis PAK® Kitabis PAK®
    Koate-DVI® Koate-DVI®
    Kogenate FS® Kogenate FS®
    Kombiglyze XR® Kombiglyze XR®
    Korlym® Korlym®
    Kuvan® Kuvan®
    Kynamro® Kynamro®

    L

    Drug Name
    Drug Criteria
    Lastacaft® Lastacaft®
    Lazanda® Lazanda®
    Lemtrada® Lemtrada®
    Lenvima® Lenvima®
    Lescol XL® Lescol XL®
    Letairis® Letairis®
    Leukine® Leukine®
    Leuprolide Acetate® Leuprolide Acetate®
    Levitra® Levitra®
    Lipitor® Lipitor®
    Liptruzet® Liptruzet®
    Livalo® Livalo®
    Lonsurf® Lonsurf®
    Lovaza® Lovaza®
    Lucentis® Lucentis®
    Lumigan® Lumigan®
    Lumizyme® Lumizyme®
    Lunesta® Lunesta®
    Lupron Depot® Lupron Depot®
    Lupron Depot-PED® Lupron Depot-PED®
    Lynparaza® Lynparaza®

    M

    Drug Name
    Drug Criteria
    Macugen® Macugen®
    Matzim LA® Matzim LA®
    Mekinist® Mekinist®
    Menopur® Menopur®
    Mircera® Mircera®
    Moderiba® Moderiba®
    Monoclate-P® Monoclate-P®
    Mononine® Mononine®
    Monovisc® Monovisc®
    Myalept® Myalept®
    Myobloc® Myobloc®
    Myozyme® Myozyme®

    N

    Drug Name
    Drug Criteria
    Naglazyme® Naglazyme®
    Naprelan® Naprelan®
    Natesto® Natesto®
    Natpara® Natpara®
    Nesina® Nesina®
    Neulasta® Neulasta®
    Neupogen® Neupogen®
    Nexavar® Nexavar®
    Ninlaro® Ninlaro®
    Norditropin Flexpro® Norditropin Flexpro®
    Noritate® Noritate®
    Northera® Northera®
    Norvasc® Norvasc®
    Novoseven® Novoseven®
    Nplate® Nplate®
    Nutropin AQ® Nutropin AQ®

    O

    Drug Name
    Drug Criteria
    Octagam® Octagam®
    Octreotide Acetate® Octreotide Acetate®
    Odomzo® Odomzo®
    Ofev® Ofev®
    Olux-E® Olux-E®
    Olysio® Olysio®
    Omega-3-Acid Ethyl Esters® Omega-3-Acid Ethyl Esters®
    Omnaris® Omnaris®
    Omnitrope® Omnitrope®
    Onglyza® Onglyza®
    Onsolis® Onsolis®
    Opsumit® Opsumit®
    Oral Pain Meds Post QL® Oral Pain Meds Post QL®
    Orencia IV® Orencia IV Policy®
    Orencia SQ® Orencia SQ Policy®
    Orenitram® Orenitram®
    Orfadin® Orfadin®
    Orkambi® Orkambi®
    Orthovisc® Orthovisc®
    Oseni® Oseni®
    Otezla® Otezla®
    Otrexup® Otrexup®
    Ovidrel® Ovidrel®
    Oxycontin® Oxycontin®
    Oxytrol® Oxytrol®

    P

    Drug NameDrug Criteria
    Pegasys® Pegasys®
    Pennsaid® Pennsaid®
    Perjeta® Perjeta®
    Plavix® Plavix®
    Plegridy® Plegridy®
    Pomalyst® Pomalyst®
    Praluent® Praluent®
    Pregnyl® Pregnyl®
    Prevacid® Prevacid®
    Privigen® Privigen®
    Procrit® Procrit®
    Procysbi® Procysbi®
    Profilnine SD® Profilnine SD®
    Prolastin-C® Prolastin-C®
    Prolia® Prolia®
    Promacta® Promacta®
    Protonix® Protonix®
    Provenge® Provenge®
    Proventil HFA® Proventil HFA®
    Pulmozyme® Pulmozyme®

    Q

    Drug Name
    Drug Criteria
    QNSL® QNSL®
    Qsymia® Qsymia®

    R

    Drug Name
    Drug Criteria
    Rasuvo® Rasuvo®
    Ravicti® Ravicti®
    Rayos® Rayos®
    Rebetol® Rebetol®
    Rebif® Rebif®
    Reclast® Reclast®
    Recombinate® Recombinate®
    Regranex® Regranex®
    Relistor® Relistor®
    Remicade® Remicade®
    Remoulin® Remoulin®
    Repatha® Post Limit Repatha® Post Limit Policy
    Replax® Post Limit Replax® Post Limit
    Repronex® Repronex®
    Retin-A® Retin-A®
    Revatio® Revatio®
    Revlimid® Revlimid®
    Rhinocort Aquia® Rhinocort Aquia®
    Riastap® Riastap®
    Ribashpere® Ribashpere®
    Ribavirn® Ribavirn®
    Riomet® Riomet®
    Rituxan® Rituxan®
    Rixubis® Rixubis®
    Rozerem® Rozerem®
    Rubraca® Rubraca®
    Ruconest® Ruconest®

    S

    Drug Name
    Drug Criteria
    Sabril® Sabril®
    Saizen® Saizen®
    Samsca® Samsca®
    Sandostatin® Sandostatin®
    Sandostatin Lar Depot® Sandostatin Lar Depot®
    Senispar® Senispar®
    Serostim® Serostim®
    Signifor® Signifor®
    Sildenafil® Sildenafil®
    Simponi® Simponi Policy®
    Simponi Aria® Simponi Aria Policy®
    Sodium Phenylbutyrate® Sodium Phenylbutyrate®
    Soliris® Soliris®
    Solodyn(Step Therapy)® Solodyn(Step Therapy)®
    Solodyn Step Therapy (Brand Only)® Solodyn Step Therapy (Brand Only)®
    Somatuline Depot® Somatuline Depot®
    Somavert® Somavert®
    Sovaldi® Sovaldi®
    Spinraza® Spinraza®
    Sprycel® Sprycel®
    Stelara IV® Stelara® IV Policy
    Stelara® SQ Stelara® SQ Policy
    Stivarga® Stivarga®
    Strensiq® Strensiq®
    Subsys® Subsys®
    Supartz® Supartz®
    Sutent® Sutent®
    Sylatron® Sylatron®
    Symbicort® Symbicort®
    Synagis® Synagis®

    T

    Drug Name
    Drug Criteria
    Taltz® Taltz®
    Taflinar® Taflinar®
    Tarceva® Tarceva®
    Targretin® Targretin®
    Tasigna® Tasigna®
    Taxotere® Taxotere®
    Tazorac® Tazorac®
    Tecfidera® Tecfidera®
    Technivie® Technivie®
    Temodar® Temodar®
    Temozolomide® Temozolomide®
    Test Strips(Non-One Touch Brands)® Test Strips(Non-One Touch Brands)®
    Testim® Testim®
    Testosterone Gel 1% 5® Testosterone Gel 1% 5®
    Tetrabenazine® Tetrabenazine®
    Teveten® Teveten®
    Teveten HCT® Teveten HCT®
    Tev-Tropin® Tev-Tropin®
    Thalomid® Thalomid®
    Tikosyn® Tikosyn®
    Tobi® Tobi®
    Tobramycin® Tobramycin®
    Toviaz® Toviaz®
    Tracleer® Tracleer®
    Treanda® Treanda®
    Trelstar® Trelstar®
    Tretinoin Products® Tretinoin Products®
    Tretin-X® Tretin-X®
    Tretten® Tretten®
    Treximet Post Limit® Treximet Post Limit®
    Tricor® Tricor®
    Tudorza® Tudorza®
    Tykerb® Tykerb®
    Tysabri® Tysabri®
    Tyvaso Starter® Tyvaso Starter®

    U

    Drug NameDrug Criteria
    Uptravi® Uptravi®

    V

    Veltin®
    Drug Name
    Drug Criteria
    Valchlor® Valchlor®
    Valcyte® Valcyte®
    Valtrex® Valtrex®
    Vantas® Vantas®
    Vascepa® Vascepa®
    Velcade® Velcade®
    Veletri® Veletri®
    Veltin®
    Venclexta®
    Ventavis® Ventavis®
    Ventolin HFA® Ventolin HFA®
    Veramyst® Veramyst®
    Viagra® Viagra®
    Vidaza® Vidaza®
    Viekira PAK® Viekira PAK®
    Vimizim® Vimizim®
    Vimovo® Vimovo®
    Visudyne® Visudyne®
    Vogelxo® Vogelxo®
    Votrient® Votrient®
    VPRIV® VPRIV®

    W

    Drug NameDrug Criteria
    Wilate® Wilate®

    X

    Drug Name
    Drug Criteria
    Xalkori® Xalkori®
    Xeljanz® Xeljanz®
    Xeloda® Xeloda®
    Xenazine® Xenazine®
    Xeomin® Xeomin®
    Xgeva® Xgeva®
    Xifaxan® Xifaxan®
    Xolair® Xolair®
    Xopenex HFA® Xopenex® HFA Policy
    Xtandi® Xtandi®
    Xyntha® Xyntha®

    Y

    Drug Name
    Drug Criteria
    Yervoy® Yervoy®

    Z

    Drug Name
    Drug Criteria
    Zarxio® Zarxio®
    Zavesca® Zavesca®
    Zecuity® Zecuity®
    Zelboraf® Zelboraf®
    Zemaira® Zemaira®
    Zetonna® Zetonna®
    Zoladex® Zoladex®
    Zoledronic Acid® Zoledronic Acid®
    Zolinza® Zolinza®
    Zomacton® Zomacton®
    Zometa® Zometa®
    Zorbtive® Zorbtive®
    Zubsolv® Zubsolv®
    Zydelig® Zydelig®
    Zykadia® Zykadia®
    Zytiga® Zytiga®