Employer Choice / Commercial Choice Prior Authorization Forms and Clinical Guidelines

BMC HealthNet Plan members and providers can search the BMC HealthNet Plan Formulary for coverage of specific medications. If the provider feels that it is medically necessary for a member to take a medication belonging to a pharmacy program, he/she may submit a prior authorization request to the Plan by fax or online submission using the appropriate form below. 

• If the request meets criteria, BMC HealthNet Plan will cover the drug.
• If the request is denied, the member and the authorized appeal representative have the right to appeal the decision. 

Please review clinical guidelines before submitting prior authorization requests. Be sure to provide complete information on the form. Contact us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

 A B C D E F G H I J K L M N O P Q R S T U V W X YZ

A

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Medical Drug Name	Clinical Criteria	Prior Authorization Form
Accu-Chek	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Actemra	Biologic DMARDs	Biologic DMARDs PA Form
Adcirca	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Advate rAHF-PFM	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Alfuzosin	BPH Medications	BPH Medications PA Form
Alphanate, Alphanate VWF	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Alphanine SD	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Amevive	Biologic DMARDs	Biologic DMARDs PA Form
Amitiza	Amitiza	Amitiza PA Form
Ampyra	Multiple Sclerosis	Multiple Sclerosis PA Form
Anadrol	Anabolic Steroids	Anabolic Steroids PA Form
Aranesp	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Arcalyst	IL-1 Antagonists	IL-1 Antagonists PA Form
Avodart	BPH Medications	BPH Medications PA Form

B

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Bebulin VH	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
BeneFIX	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Benlysta	Biologic DMARDs	Biologic DMARDs PA Form
Bebulin VH	Antihemophilic Medications	Antihemophilic Medications PA Form
Botox	Botulinum Toxin	Botulinum Toxin PA Form
Botulinum Toxin	Botulinum Toxin	Botulinum Toxin PA Form
Bravelle	Infertility Medications	Infertility PA Form

C

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Cardura XL	BPH Medications	BPH Medications PA Form
Centrotide	Infertility Medications	Infertility PA Form
Chorionic Gonadotropin	Infertility Medications	Infertility PA Form
Cialis	BPH Medications	BPH Medications PA Form
Cimzia	Biologic DMARDs	Biologic DMARDs PA Form
Cinryze	Hereditary Angioedema	Hereditary Angioedema PA Form
Clomiphene Citrate	Infertility Medications	Infertility PA Form
Corifact	Blood Clotting Disorders Medications	Blood Clotting Disorders Medications PA Form
Crinone	Infertility Medications	Infertility PA Form

D

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Darbepoietin	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
degarelix	GnRH Agents	GnRH Agents PA Form
Depot	GnRH Agents	GnRH Agents PA Form
Depot Ped	GnRH Agents	GnRH Agents PA Form
Dex	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Dificid	Antibiotics (systemic)	Antibiotics (systemic) PA Form
doxazosin extend-release	BPH Medications	BPH Medications PA Form
dutasteride	BPH Medications	BPH Medications PA Form
Dysport	Botulinum Toxin	Botulinum Toxin PA Form

E

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Egrifta	Egrifta	Egrifta PA Form
Eligard	GnRH Agents	GnRH Agents PA Form
Elite	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Enbrel	Biologic DMARDs	Biologic DMARDs PA Form
Endometrin	Infertility Medications	Infertility Medications PA Form
Epogen	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Epoprostenol	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Erythropoietin	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Euflexxa	Viscosupplements	Viscosupplements PA Form
Exjade	Exjade	Exjade PA Form

F

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Factor VIII & IX	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Feiba VH NF	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Firmagon	GnRH Agents	GnRH Agents PA Form
Follistim AQ	Infertility Medications	Infertility Medications PA Form
Forteo	Forteo-Prolia-Xgeva	Forteo-Prolia-Xgeva PA Form

G

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Ganirelix Acetate	Infertility Medications	Infertility PA Form
Gardasil	HPV Vaccines	Medical Benefit PA Form
Gilenya	Multiple Sclerosis	Multiple Sclerosis PA Form
Gonal-F	Infertility Medications	Infertility PA Form
Goserelin	GnRH Agents	GnRH Agents PA Form

H

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Helixate FS	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Hemofil-M	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Histrelin	GnRH Agents	GnRH Agents PA Form
Human Papillomavirus	HPV Vaccines	Medical Benefit PA Form
Humate-P	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Humira	Biologic DMARDs	Biologic DMARDs PA Form
Hyalgan	Viscosupplements	Viscosupplements PA Form
Hyate:C	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Hydroxyprogesterone Caproate	Makena	Makena PA Form

I

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Ilaris	IL-1 Antagonists	IL-1 Antagonists PA Form
Incivek	Hepatitis C	Hepatitis C PA Form
IncobotulinumtoxinA	Botulinum Toxin	Botulinum Toxin PA Form
Increlex	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Infergen	Hepatitis C	Hepatitis C PA Form
Interferon Alfa-2a	Hepatitis C	Hepatitis C PA Form
Interferon Alfa-2b	Hepatitis C	Hepatitis C PA Form
Interferon-Alfacon-1	Hepatitis C	Hepatitis C PA Form
Iprivask	Iprivask	Iprivask PA Form

J

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Jalyn

BPH Medications

BPH Medications PA Form

K

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Kineret	Biologic DMARDs	Biologic DMARDs PA Form
Kineret	Biologic DMARDs	Biologic DMARDs PA Form
Koate-DVI	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Kogenate FS	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Krystexxa	Anti Gout Medications	Anti Gout Medications PA Form

L

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Letairis	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Leuprolide	GnRH Agents	GnRH Agents PA Form
Linezolid		Zyvox PA Form
Lovaza	Lovaza	Lovaza PA Form
Lupron, Lupron Depot, Lupron Depot Ped	GnRH Agents	GnRH Agents PA Form
Luveris	Infertility Medications	Infertility PA Form

M

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Makena	Makena	Makena PA Form
Menopur	Infertility Medications	Infertility PA Form
Modafinil	Provigil-Nuvigil	Provigi-lNuvigil PA Form
Monarc-M	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Monoclate-P	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Mononine	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Mozobil	Mozobil	Mozobil PA Form
Myobloc	Botulinum Toxin	Botulinum Toxin PA Form

N

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Norditropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Novarel	Infertility Medications	Infertility PA Form
NovoSeven, NovoSeven RT	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Nplate	Nplate	Nplate PA Form
Nutropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Nuvigil	Provigil-Nuvigil	Provigi-lNuvigil PA Form

O

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Omega-3-Acid Ethyl Esters	Lovaza	Lovaza PA Form
Omnitrope	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
One Touch	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Orencia	Biologic DMARDs	Biologic DMARDs PA Form
Orthovisc	Viscosupplements	Viscosupplements PA Form
Ovidrel	Infertility Medications	Infertility PA Form
Oxandrolone	Anabolic Steroids	Anabolic Steroids PA Form

P

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Pegasys	Hepatitis C	Hepatitis C PA Form
PEG-Intron	Hepatitis C	Hepatitis C PA Form
Plerixafor	Mozobil	Mozobil PA Form
Pradaxa	Anticoagulants (Oral)	Anticoagulants (Oral) PA Form
Pregnyl	Infertility Medications	Infertility PA Form
Prochieve	Infertility Medications	Infertility PA Form
Procrit	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Profilnine SD	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Prolia	Forteo-Prolia-Xgeva	Forteo-Prolia-Xgeva PA Form
Promacta	Promacta	Promacta PA Form
Protropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Provigil	Provigil-Nuvigil	Provigi-lNuvigil PA Form

Q

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Qutenza

Qutenza

Qutenza PA Form

R

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Ranexa	Ranexa	Ranexa PA Form
Ranolazine Extended Release	Ranexa	Ranexa PA Form
Rapaflo	BPH Medications	BPH Medications PA Form
Rebetol	Hepatitis C	Hepatitis C PA Form
Recombinate	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Refacto	Blood Clotting Disorder Medications	Blood Clotting Disorder PA Form
Relistor	Relistor	Relistor PA Form
Remicade	Biologic DMARDs	Biologic DMARDs PA Form
Remodulin	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Repronex	Infertility Medications	Infertility PA Form
Revatio	Pulmonary Hypertension	Pulmonary Hypertension PA Form
RFF	Infertility Medications	Infertility PA Form
Ribapak	Hepatitis C	Hepatitis C PA Form
Rituxan	Biologic DMARDs	Biologic DMARDs PA Form

S

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Saizen	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Samsca	Samsca	Samsca PA Form
Selzentry	Selzentry	Selzentry PA Form
silodosin	BPH Medications	BPH Medications PA Form
Simponi	Biologic DMARDs	Biologic DMARDs PA Form
Stelara	Biologic DMARDs	Biologic DMARDs PA Form
Suboxone Film	Suboxone-Buprenorphine HCL	Suboxone-Buprenorphine HCL PA Form
Supartz	Viscosupplements	Viscosupplements PA Form
Supprelin LA	GnRH Agents	GnRH Agents PA Form
Synagis	Synagis	Synagis PA Form
Synvisc	Viscosupplements	Viscosupplements PA Form
Synvisc-One	Viscosupplements	Viscosupplements PA Form

T

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tadalafil	BPH Medications	BPH Medications PA Form
Tolvaptan	Samsca	Samsca PA Form
Tracleer	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Trelstar Depot	GnRH Agents	GnRH Agents PA Form
Trelstar Depot	GnRH Agents	GnRH Agents PA Form
Tracleer	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Trelstar Depot	GnRH Agents	GnRH Agents PA Form
Tyvaso	Pulmonary Hypertension	Pulmonary Hypertension PA Form

U

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Uloric

Anti-Gout Medications

Anti-Gout Medications PA Form

V

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Vatas	GnRH Agents	GnRH Agents PA Form
Veletri	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Ventavis	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Victoza	Victoza	Victoza PA Form
Victrelis	Hepatitis C	Hepatitis C PA Form
Vivitrol	Vivitrol	Vivitrol PA Form

W

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Wilate

Blood Clotting Disorder Medications

Blood Clotting Disorder Medications PA Form

X

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Xarelto	Anticoagulants (Oral)	Anticoagulants (Oral) PA Form
Xeomin	Botulinum Toxin	Botulinum Toxin PA Form
Xgeva	Forteo-Prolia-Xgeva	Forteo-Prolia-Xgeva PA Form
Xiaflex	Xiaflex	Xiaflex PA Form
Xifaxan	Antibiotics (systemic)	Antibiotics (systemic) PA Form
Xolair	Xolair	Xolair PA Form
Xyntha	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form

Y

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Z

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Zoladex	GnRH Agents	GnRH Agents PA Form
Zyvox	Antibiotics (systemic)	Antibiotics (systemic) PA Form