Prior Authorization
Prior Authorization is a tool that helps decide whether or not a prescription is covered before it is filled. The approval or denial is based on the plan design and focuses on safety and proper medication use. If a drug on the Mount Carmel MediGold Health Plan formulary requires prior authorization, you will see the abbreviation "PA" in the formulary.
You may also see drugs in the formulary marked with "B/D". This means that the drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
Please have your pharmacist or doctor call CVS Caremark’s Prior Authorization department at 1-800-294-5979 (TTY 711) before prescribing or administering drugs that require prior authorization.
2024 Prior Authorization Criteria (last updated 05/01/2024)
2024 Prior Authorization Forms
Click any drug name below to view the corresponding prior authorization fax form.
Drugs are listed in alphabetical order. To jump to a specific section, click the letter below that corresponds with the first letter for the drug you are inquiring about:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
A
Acitretin 2024 PA Fax 1459-A V1 01-01-24
Actimmune 2024 PA Fax 562-A V1 01-01-24
Adalimumab 2024 PA Fax 107-A V3 01-01-24
Adempas 2024 PA Fax 1048-A V1 01-01-24
Afinitor 2024 PA Fax 415-A V1 01-01-24
Aimovig 2024 PA Fax 3193-A V1 01-01-24
Akeega 2024 PA Fax 6136-A V1 01-01-24
Albendazole 2024 PA Fax 5812-A V1 01-01-24
Aldurazyme 2024 PA Fax 573-A V1 01-01-24
Alecensa 2024 PA Fax 1322-A V1 01-01-24
Alpha-1 Proteinase Inhibitors 2024 PA Fax 11-A V1 01-01-24
Alunbrig 2024 PA Fax 1816-A V2 01-01-24
Ambrisentan 2024 PA Fax 640-A V1 01-01-24
Amphetamines 2024 PA Fax 1383-A V1 01-01-24
Ampyra 2024 PA Fax 477-A V1 01-01-24
Ancobon 2024 PA Fax 4603-A V1 01-01-24
Antiemetics 2024 PA Fax BD-16 V1 01-01-24
Arcalyst 2024 PA Fax 597-A V1 01-01-24
Austedo 2024 PA Fax 1748-A V2 01-01-24
Ayvakit 2024 PA Fax 3495-A V1 01-01-24
B
Bafiertam 2024 PA Fax 3884-A V1 01-01-24
Balversa 2024 PA Fax 2966-A V1 01-01-24
Banzel 2024 PA Fax 1386-A V1 01-01-24
Benlysta 2024 PA Fax 862-A V2 01-01-24
Besremi 2024 PA Fax 5062-A V1 01-01-2
Bosulif 2024 PA Fax 806-A V1 01-01-24
Braftovi 2024 PA Fax 2615-A V2 01-01-24
Briviact 2024 PA Fax 4558-A V3 01-01-24
Bronchitol 2024 PA Fax 4340-A V1 01-01-24
Brukinsa 2024 PA Fax 3414-A V3 01-01-24
Budesonide 2024 PA Fax 4498-A V1 01-01-24
Buprenorphine SL 2024 PA Fax 1391-A V1 01-01-24
Bydureon 2024 PA Fax 5567-A V2 01-01-2
Byetta 2024 PA Fax 5568-A V3 01-01-24
C
Cabometyx 2024 PA Fax 1367-A v1 010124_508
Calquence 2024 PA Fax 2398-A v4 010124_508
Caplyta 2024 PA Fax 4531-A v2 010124_508
Caprelsa 2024 PA Fax 801-A v1 010124_508
Carbaglu 2024 PA Fax 840-A v1 010124_508
Cayston 2024 PA Fax 480-A v1 010124_508
Cerdelga 2024 PA Fax 1188-A v1 010124_508
Cerezyme 2024 PA Fax 1497-A v1 010124_508
Chantix 2024 PA Fax 1393-A v1 010124_508
Clobazam 2024 PA Fax 1443-A v1 010124_508
Clomipramine 2024 PA Fax 2484-A v1 010124_508
Clozapine ODT 2024 PA Fax 1403-A v1 010124_508
Cometriq 2024 PA Fax 916-A v1 010124_508
Copiktra 2024 PA Fax 2755-A v1 010124_508
Cotellic 2024 PA Fax 1307-A v2 010124_508
Cystagon 2024 PA Fax 803-A v1 010124_508
Cysteamine opth 2024 PA Fax 926-A v1 010124_508
D
Daurismo 2024 PA Fax 2794-A v1 010124_508
Deferasirox 2024 PA Fax 553-A v1 010124_508
Demser 2024 PA Fax 2531-A v1 010124_508
Desvenlafaxine ER 2024 PA Fax 2485-A v1 010124_508
Dexmethylphenidate 2024 PA Fax 4336-A v1 010124_508
DHE Nasal 2024 PA Fax 2895-A v1 010124_508
Diacomit 2024 PA Fax 2779-A v2 010124_508
Diazepam PA Plus 2024 PA Fax 1473-B v1 010124_508
Disposable Insulin Pumps 2024 PA Fax 3573-A v1 010124_508
Doptelet 2024 PA Fax 2586-A v1 010124_508
Dupixent 2024 PA Fax 1691-A v6 010124_508
E
Eligard 2024 PA Fax 5263-A v1 010124_508
Emend Varubi 2024 PA Fax BD-3 v1 010124_508
Emsam 2024 PA Fax 1401-A v1 010124_508
Enbrel 2024 PA Fax 80-A v1 010124_508
Endari 2024 PA Fax 2211-A v1 010124_508
Epclusa 2024 PA Fax 1508-A v2 010124_508
Epidiolex 2024 PA Fax 2608-A v1 010124_508
Epoetin 2024 PA Fax 81-A v2 010124_508
Eprontia 2024 PA Fax 5286-A v2 010124_508
Ergotamine 2024 PA Fax 4607-A v1 010124_508
Erivedge 2024 PA Fax 762-A v1 010124_508
Erleada 2024 PA Fax 2499-A v1 010124_508
Esbriet 2024 PA Fax 1217-A v1 010124_508
Exkivity 2024 PA Fax 4967-A v1 010124_508
F
Fabrazyme 2024 PA Fax 576-A v1 010124_508
Fanapt 2024 PA Fax 4533-A v2 010124_508
Fasenra 2024 PA Fax 2414-A v2 010124_508
Fentanyl Patch 2024 PA Fax 1398-A v1 010124_508
Fetzima 2024 PA Fax 1404-A v1 010124_508
Fintepla 2024 PA Fax 3983-A v1 010124_508
Firmagon 2024 PA Fax 3873-A v1 010124_508
Fotivda 2024 PA Fax 4620-A v1 010124_508
Fycompa 2024 PA Fax 4557-A v2 010124_508
G
Gattex 2024 PA Fax 938-A v1 010124_508
Gavreto 2024 PA Fax 4207-A v1 010124_508
Gilenya 2024 PA Fax 620-A v1 010124_508
Gilotrif 2024 PA Fax 1011-A v1 010124_508
Glatiramer 2024 PA Fax 544-A v1 010124_508
Gleevec 2024 PA Fax 99-A v2 010124_508
Gralise 2024 PA Fax 2535-A v1 010124_508
Growth Hormone 2024 PA Fax 101-A v1 010124_508
H
Harvoni 2024 PA Fax 1209-A v2 010124_508
Hepatitis B 2024 PA Fax BD-5 v1 010124_508
Herceptin Hylecta BDC 2024 PA Fax 2945-A BD-13 v1 010124_508
Hetlioz 2024 PA Fax 1125-A v1 010124_508
HRM Anticonvulsants 2024 PA Fax 1410-B v1 010124_508
HRM Antiparkinson 2024 PA Fax 1416-B v1 010124_508
HRM Cyproheptadine 2024 PA Fax 3513-B v1 010124_508
HRM Dipyridamole 2024 PA Fax 3525-B v1 010124_508
HRM Guanfacine ER 2024 PA Fax 3520-B v1 010124_508
HRM Guanfacine IR 2024 PA Fax 3519-B v1 010124_508
HRM Hydroxyzine Inj 2024 PA Fax 1415-B v1 010124_508
HRM Hydroxyzine Oral 2024 PA Fax 1414-B v1 010124_508
HRM Hypnotics 2024 PA Fax 1421-B v1 010124_508
HRM Muscle Relaxants PA Plus 2024 PA Fax 1420-B v1 010124_508
HRM Promethazine 2024 PA Fax 1413-B v1 010124_508
HRM Scopolamine 2024 PA Fax 3510-B v1 010124_508
I
Ibrance 2024 PA Fax 1236-A v2 010124_508
Icatibant 2024 PA Fax 809-A v1 010124_508
Iclusig 2024 PA Fax 920-A v2 010124_508
Idhifa 2024 PA Fax 2239-A v1 010124_508
Imbruvica 2024 PA Fax 1050-A v5 010124_508
Inbrija 2024 PA Fax 2861-A v1 010124_508
Increlex 2024 PA Fax 551-A v1 010124_508
Infliximab 2024 PA Fax 187-A v1 010124_508
Infusion 2024 PA Fax BD-20 v2 010124_508
Injectables 2024 PA Fax BD-13 v1 010124_508
Inlyta 2024 PA Fax 747-A v1 010124_508
Inqovi 2024 PA Fax 4008-A v1 010124_508
Inrebic 2024 PA Fax 3162-A v1 010124_508
Interferon 2024 PA Fax 543-A v1 010124_508
Iressa 2024 PA Fax 1282-A v1 010124_508
Isotretinoins 2024 PA Fax 1430-A v1 010124_508
Ivermectin Tab 2024 PA Fax 4922-A v1 010124_508
IVIG BDC 2024 PA Fax 119-A BD-15 v1 010124_508
J
Jakafi 2024 PA Fax 723-A v1 010124_508
Jaypirca 2024 PA Fax 5769-A v1 010124_508
Jynneos 2024 PA Fax BD-25 v1 010124_508
K
Kalydeco 2024 PA Fax 753-A v2 010124_508
Kesimpta 2024 PA Fax 4122-A v1 010124_508
Ketoconazole PO 2024 PA Fax 1440-A v1 010124_508
Kevzara 2024 PA Fax 1958-A v3 010124_508
Keytruda 2024 PA Fax 1185-A v7 010124_508
Kisqali-Kisqali Femara 2024 PA Fax 1638-A v3 010124_508
Korlym 2024 PA Fax 778-A v1 010124_508
Koselugo 2024 PA Fax 3771-A v1 010124_508
Krazati 2024 PA Fax 5702-A v1 010124_508
L
Lenvima 2024 PA Fax 1248-A v1 010124_508
Leuprolide inj 2024 PA Fax 4629-A v3 010124_508
Lidocaine Topical 2024 PA Fax 1434-A v2 010124_508
Lidoderm ZTLido 2024 PA Fax 1433-A v1 010124_508
Lonsurf 2024 PA Fax 1298-A v1 010124_508
Lorbrena 2024 PA Fax 2788-A v1 010124_508
Lotronex 2024 PA Fax 1435-A v1 010124_508
Lovaza 2024 PA Fax 2480-A v1 010124_508
Lumakras 2024 PA Fax 4762-A v1 010124_508
Lumizyme 2024 PA Fax 593-A v1 010124_508
Lupron Endometriosis 2024 PA Fax 567-A v2 010124_508
Lupron PED 2024 PA Fax 549-A v1 010124_508
Lynparza 2024 PA Fax 1232-A v4 010124_508
Lyrica 2024 PA Fax 2898-A v2 010124_508
Lytgobi 2024 PA Fax 5648-A v2 010124_508
M
Mavyret 2024 PA Fax 2243-A v2 010124_508
Megestrol 2024 PA Fax 1437-A v1 010124_508
Mekinist 2024 PA Fax 999-A v3 010124_508
Mektovi 2024 PA Fax 2613-A v2 010124_508
Methylphenidate 2024 PA Fax 3642-A v1 010124_508
Methyltestosterone 2024 PA Fax 3707-A v1 010124_508
Miglustat 2024 PA Fax 580-A v2 010124_508
Monjuvi 2024 PA Fax 4057-A v2 010124_508
N
Naglazyme 2024 PA Fax 577-A v1 010124_508
Namenda 2024 PA Fax 1439-B v1 010124_508
Natpara 2024 PA Fax 1263-A v1 010124_508
Nebs-Asthma COPD 2024 PA Fax BD-8 v2 010124_508
Nebs-Mucolytics 2024 PA Fax BD-10 v2 010124_508
Nebs-Pentamidine 2024 PA Fax BD-11 v1 010124_508
Nerlynx 2024 PA Fax 2180-A v1 010124_508
Nexavar 2024 PA Fax 417-A v1 010124_508
Ninlaro 2024 PA Fax 1312-A v1 010124_508
Nitisinone 2024 PA Fax 579-A v1 010124_508
Northera 2024 PA Fax 1142-A v1 010124_508
Noxafil Sus 2024 PA Fax 4505-A v1 010124_508
Noxafil Tab 2024 PA Fax 4504-A v1 010124_508
Nubeqa 2024 PA Fax 3149-A v2 010124_508
Nuedexta 2024 PA Fax 1441-A v1 010124_508
Nulojix 2024 PA Fax BD-26 v1 010124_508
Nuplazid 2024 PA Fax 1366-A v1 010124_508
Nurtec ODT 2024 PA Fax 4556-A v1 010124_508
Nuvigil 2024 PA Fax 1442-A v1 010124_508
O
Octreotide 2024 PA Fax 4361-A v1 010124_508
Odomzo 2024 PA Fax 1283-A v1 010124_508
Ofev 2024 PA Fax 1216-A v1 010124_508
Ojjaara 2024 PA Fax 6190-A v1 010124_508
Onureg 2024 PA Fax 4196-A v1 010124_508
Opioids ER 2024 PA Fax 2493-A v2 010124_508
Opsumit 2024 PA Fax 1049-A v1 010124_508
Oral Chemo 2024 PA Fax BD-17 v1 010124_508
Oral Intranasal Fentanyl 2024 PA Fax 1445-A v1 010124_508
Orgovyx 2024 PA Fax 4413-A v1 010124_508
Orkambi 2024 PA Fax 1279-A v1 010124_508
Orserdu 2024 PA Fax 5776-A v1 010124_508
Otezla 2024 PA Fax 1129-A v1 010124_508
Ozempic 2024 PA Fax 5569-A v2 010124_508
P
Panretin 2024 PA Fax 4861-A v1 010124_508
Parenteral Nutrition 2024 PA Fax BD-18 v1 010124_508
Paxil Sus 2024 PA Fax 4617-A v1 010124_508
Pegasys 2024 PA Fax 556-A v2 010124_508
Pegfilgrastim 2024 PA Fax 153-A v2 010124_508
Pemazyre 2024 PA Fax 3823-A v3 010124_508
Phenylbutyrate 2024 PA Fax v2 010124_508
Phesgo 2024 PA Fax 3987-A v1 010124_508
Piqray 2024 PA Fax 3090-A v1 010124_508
Pomalyst 2024 PA Fax 963-A v1 010124_508
Prevymis 2024 PA Fax 4788-A v3 010124_508
Promacta 2024 PA Fax 592-A v2 010124_508
Provigil 2024 PA Fax 1450-A v1 010124_508
Pulmozyme BDC 2024 PA Fax 563-A BD-10 v1 010124_508
Q
Qinlock 2024 PA Fax 3902-A v2 010124_508
Qualaquin 2024 PA Fax 1451-A v1 010124_508
Qulipta 2024 PA Fax 5001-A v3 010124_508
R
Rabies Vaccine 2024 PA Fax BD-23 v1 010124_508
Regranex 2024 PA Fax 1453-A v1 010124_508
Relistor Inj 2024 PA Fax 1454-A v1 010124_508
Renflexis 2024 PA Fax 3947-A v1 010124_508
Repatha 2024 PA Fax 1774-A v1 010124_508
Retevmo 2024 PA Fax 3875-A v3 010124_508
Revlimid 2024 PA Fax 386-A v1 010124_508
Rezlidhia 2024 PA Fax 5684-A v2 010124_508
Rezurock 2024 PA Fax 4854-A v1 010124_508
Rinvoq 2024 PA Fax 3186-A v2 010124_508
Rozlytrek 2024 PA Fax 3166-A v2 010124_508
Rubraca 2024 PA Fax 1569-A v2 010124_508
Rybelsus 2024 PA Fax 5570-A v2 010124_508
Rydapt 2024 PA Fax 1818-A v1 010124_508
S
Sapropterin 2024 PA Fax 341-A v1 010124_508
Savella 2024 PA Fax 3534-A v1 010124_508
Scemblix 2024 PA Fax 5048-A v1 010124_508
Seroquel XR 2024 PA Fax 2875-A v1 010124_508
Signifor 2024 PA Fax 970-A v1 010124_508
Sildenafil PO 2024 PA Fax 641-A v2 010124_508
Sirturo 2024 PA Fax 1456-A v1 010124_508
Skyrizi 2024 PA Fax 3048-A v1 010124_508
Somatuline Depot 2024 PA Fax 671-A v1 010124_508
Somavert 2024 PA Fax 564-A v1 010124_508
Sporanox Capsules 2024 PA Fax 1432-A v1 010124_508
Sprycel 2024 PA Fax 422-A v1 010124_508
Stelara 2024 PA Fax 560-A v4 010124_508
Stivarga 2024 PA Fax 820-A v2 010124_508
Sutent 2024 PA Fax 418-A v2 010124_508
Symdeko 2024 PA Fax 2515-A v1 010124_508
Synarel 2024 PA Fax 5802-A v1 010124_508
Synribo 2024 PA Fax 886-A v2 010124_508
Syprine 2024 PA Fax 2486-A v1 010124_508
T
Tabrecta 2024 PA Fax 3879-A v1 010124_508
Tafinlar 2024 PA Fax 1000-A v2 010124_508
Tagrisso 2024 PA Fax 1305-A v2 010124_508
Taltz 2024 PA Fax 1351-A v1 010124_508
Talzenna 2024 PA Fax 2781-A v3 010124_508
Tarceva 2024 PA Fax 223-A v1 010124_508
Targretin caps 2024 PA Fax 507-A v1 010124_508
Targretin Gel 2024 PA Fax 4618-A v1 010124_508
Tasigna 2024 PA Fax 421-A v1 010124_508
Tazorac 2024 PA Fax 1462-A v1 010124_508
Tazverik 2024 PA Fax 3503-A v1 010124_508
Tecentriq 2024 PA Fax 1374-A v3 010124_508
Temazepam 2024 PA Fax 3501-B v1 010124_508
Tepmetko 2024 PA Fax 4496-A v1 010124_508
Teriparatide 2024 PA Fax 94-A v2 010124_508
Testosterone Cypionate 2024 PA Fax 1464-A v1 010124_508
Testosterone Enanthate 2024 PA Fax 1463-A v1 010124_508
Testosterone Topical 2024 PA Fax 1465-A v1 010124_508
Tetanus Vaccine 2024 PA Fax BD-19 v1 010124_508
Tetracycline 2024 PA Fax 3541-A v1 010124_508
Thalomid 2024 PA Fax 230-A v1 010124_508
Tibsovo 2024 PA Fax 2637-A v2 010124_508
Tobramycin BDC 2024 PA Fax 232-A BD-12 v1 010124_508
Tracleer 2024 PA Fax 234-A v1 010124_508
Tranxene T 2024 PA Fax 1466-B v1 010124_508
Trastuzumab BDC 2024 PA Fax 1499-A BD-13 v2 010124_508
Trazimera BDC 2024 PA Fax 3945-A BD-13 v2 010124_508
Treprostinil BDC 2024 PA Fax 188-A BD-20 v1 010124_508
Tretinoins Topical 2024 PA Fax 1467-A v1 010124_508
Trikafta 2024 PA Fax 3375-A v2 010124_508
Trulicity 2024 PA Fax 5571-A v2 010124_508
Truxima 2024 PA Fax 4710-A v3 010124_508
Tukysa 2024 PA Fax 3781-A v2 010124_508
Turalio 2024 PA Fax 3152-A v1 010124_508
Tykerb 2024 PA Fax 308-A v1 010124_508
U
Ubrelvy 2024 PA Fax 3485-A v1 010124_508
Uceris 2024 PA Fax 4500-A v1 010124_508
Uloric 2024 PA Fax 2885-A v1 010124_508
V
Valchlor 2024 PA Fax 1044-A v1 010124_508
Vanflyta 2024 PA Fax 6087-A v1 010124_508
Velcade BDC 2024 PA Fax 763-A BD-13 v1 010124_508
Venclexta 2024 PA Fax 1353-A v1 010124_508
Ventavis BDC 2024 PA Fax 240-A BD-9 v1 010124_508
Versacloz 2024 PA Fax 4553-A v2 010124_508
Verzenio 2024 PA Fax 2343-A v2 010124_508
Vfend 2024 PA Fax 2877-A v1 010124_508
Vigabatrin 2024 PA Fax 548-A v2 010124_508
Vitamin D Topical 2024 PA Fax 2569-A v1 010124_508
Vitrakvi 2024 PA Fax 2801-A v1 010124_508
Vizimpro 2024 PA Fax 2771-A v1 010124_508
Vonjo 2024 PA Fax 5264-A v2 010124_508
Vosevi 2024 PA Fax 2177-A v1 010124_508
Votrient 2024 PA Fax 547-A v2 010124_508
Vyvanse 2024 PA Fax 3674-A v2 010124_508
W
Welireg 2024 PA Fax 4902-A v1 010124_508
X
Xalkori 2024 PA Fax 697-A v2 010124_508
Xeljanz 2024 PA Fax 914-A v1 010124_508
Xenazine 2024 PA Fax 360-A v2 010124_508
Xermelo 2024 PA Fax 1671-A v1 010124_508
Xgeva BDC 2024 PA Fax 637-A BD-13 v1 010124_508
Xhance 2024 PA Fax 4539-A v2 010124_508
Xifaxan 550mg 2024 PA Fax 1480-A v1 010124_508
Xolair 2024 PA Fax 473-A v3 010124_508
Xospata 2024 PA Fax 2808-A v1 010124_508
Xpovio 2024 PA Fax 3121-A v1 010124_508
Xtandi 2024 PA Fax 816-A v1 010124_508
Xyrem 2024 PA Fax 1481-A v2 010124_508
Y
There are no drugs beginning with the letter Y that require prior authorization at this time.
Z
Zarxio 2024 PA Fax 4507-A v1 010124_508
Zejula 2024 PA Fax 1689-A v2 010124_508
Zelboraf 2024 PA Fax 696-A v2 010124_508
Zirabev BDC 2024 PA Fax 3944-A BD-13 v3 010124_508
Zolinza 2024 PA Fax 566-A v1 010124_508
Zonisade 2024 PA Fax 5624-A v1 010124_508
Ztalmy 2024 PA Fax 5338-A v1 010124_508
Zydelig 2024 PA Fax 1174-A v1 010124_508
Zykadia 2024 PA Fax 1136-A v1 010124_508
Last updated: 04/2024