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Prior Authorization Drug List

Below is a list of drugs that require prior authorization for MedBlue RxSM or MedBlue RxSM Plus members. You can click on the name of the medication and print the attached authorization form. Have your provider complete the form and fax it to the Prior Authorizations department at 1-888-836-0730.

 

Actimmune

Adderall XR

Aranesp

Avita

Delatestryl

Depo Testosterone

Dextroamphetamine

Dextrostat

Differin

Elidel

Enbrel

Epogen

Exjade

Forteo

Growth Hormone

Humira

Infergen

ltraconazole

Lamisil

Lotronex

Methylphenidate

Neupogen

Neulasta

Octreotide

Peg Intron

Pegasys

Procrit

Protopic

Provigil

Ranexa

Raptiva

Rebetol

Rebetron

Regranex

 

Remicade

Retin-A

Retin-A Micro

Revatio

Roferon

Sandostatin

Somavert

Soriatane

Strattera

Testosterone Cypionate

Thalomid

Tretinoin

Xolair

Zelnorm



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