Medicare Advantage PPO medical drug policies and forms
Need to treat a Medicare Advantage PPO patient with medical drugs given at a provider office, an outpatient facility location or the patient’s home? You’ll need to submit a prior authorization request and follow our medical policies to avoid a rejected claim. You can quickly submit by logging into Provider Secured Services and by using Novologix®.
If you have access to Provider Secured Services, you’ll also have access to the Medicare Advantage PPO Medical Benefit Medication Prior Authorization link, which allows you to enter a prior authorization request for Medicare Advantage PPO members. If you have access to Provider Secured Services or NovoLogix, you’ll need to submit your request online.
If you don’t have access to Provider Secured Services, you can submit your request for prior authorization by locating the appropriate authorization form below and faxing your request.
Drugs that require prior authorization
You can find which drugs need prior authorization by viewing our Medicare Advantage Medical Drug Prior Authorization and Step Therapy List (PDF). It includes Healthcare Common Procedural Coding System, or HCPCS, codes. It also lists generic and brand names for each drug.
Medical policies
View our medical policies to learn about our drug guidelines.
- Actemra® (tocilizumab) medical policy (PDF)
- Adakveo® (crizanlizumab-tmca) medical policy (PDF)
- Alpha-1 proteinase inhibitors medical policy (PDF)
- Benlysta® (belimumab) medical policy (PDF)
- Botulinum toxin type A medical policy (PDF)
- Botulinum toxin type B medical policy (PDF)
- Calcitonin Gene Related Peptide Antagonists medical policy (PDF)
- CAR-T Therapy medical policy (PDF)
- Cimzia® (certolizumab pegol) medical policy (PDF)
- Cinqair® (reslizumab) medical policy (PDF)
- Crysvita® (Burosumab-twza) medical policy (PDF)
- Duchenne Muscular Dystrophy medical policy (PDF)
- Entyvio® (vedolizumab) medical policy (PDF)
- Enzyme replacement therapy medical policy (PDF)
- Evenity® (romosozumab) medical policy (PDF)
- Fasenra™ (benralizumab) medical policy (PDF)
- Givlaari™ (givosiran) medical policy (PDF)
- Hemophilia Class medical policy (PDF)
- Hyaluronic acid intra-articular injections medical policy (PDF)
- Ilaris® (canakinumab) medical policy (PDF)
- Ilumya™ (tildrakizumab-asmn) medical policy (PDF)
- Immune globulin replacement therapy medical policy (PDF)
- Infliximab medical policy (PDF)
- Intravitreal injections for retinal conditions medical policy (PDF)
- Krystexxa® (pegloticase) medical policy (PDF)
- Luxturna™ (voretigene neparvovec-rzyl) medical policy (PDF)
- Nplate® (romiplostim) medical policy (PDF)
- Nucala® (mepolizumab) medical policy (PDF)
- Onpattro® (patisiran) medical policy (PDF)
- Orencia® (abatacept) medical policy (PDF)
- Prolia® and Xgeva® (denosumab) medical policy (PDF)
- Pulmonary arterial hypertension medical policy (PDF)
- Radicava® (Edaravone) medical policy (PDF)
- Reblozyl® (luspatercept-aamt) medical policy (PDF)
- Scenesse® (afamelanotide) medical policy (PDF)
- Simponi® Aria™ (golimumab) medical policy (PDF)
- Skyrizi™ (risankizumab-rzaa) medical policy (PDF)
- Soliris® (eculizumab injection) medical policy (PDF)
- Spinraza® (nusinersen) medical policy (PDF)
- Spravato™ (esketamine) medical policy (PDF)
- Stelara® (ustekinumab) medical policy (PDF)
- Tegsedi™ (inotersen) medical policy (PDF)
- Tepezza™ (teprotumumab-trbw) medical policy (PDF)
- Trogarzo™ (ibalizumab) medical policy (PDF)
- Ultomiris™ (ravulizumab) medical policy (PDF)
- Uplizna™ (inebilizumab-cdon) medical policy (PDF)
- Xiaflex® (collagenase clostridium histolyticum) medical policy (PDF)
- Xolair® (omalizumab) medical policy (PDF)
- Zilretta® (triamcinolone acetonice extended release injectable) medical policy (PDF)
- Zinplava™ (Bezlotoxumab) medical policy (PDF)
- Zolgensma® (onasemnogene abeparvovec) medical policy (PDF)
Medication prior authorization request forms
You can submit a medication prior authorization request through a web tool in Provider Secured Services or by using one of the following:
- Actemra® (tocilizumab) request form (PDF)
- Adagen® (pegademase bovine) request form (PDF)
- Adakveo® (crizanlizumab-tmca) request form (PDF)
- Alpha-1 proteinase inhibitors request form (PDF)
- Avsola™ (infliximab-axxq) request form (PDF)
- Benlysta® (belimumab) request form (PDF)
- Beovu® (brolucizumab) request form (PDF)
- Botulinum toxin type A and type B request form (PDF)
- CAR-T Therapy – Kymriah® (Tisagenlecleucel) request form (PDF)
- CAR-T Therapy – Tecartus™ (brexucabtagene autoleucel) request form (PDF)
- CAR-T Therapy – Yescarta® (Axicabtagene ciloleucel) request form (PDF)
- Cimzia® (certolizumab) request form (PDF)
- Cinqair® (reslizumab) request form (PDF)
- Crysvita® (Burosumab-twza) request form (PDF)
- Duchenne Muscular Dystrophy request form (PDF)
- Eylea® (aflibercept) and Lucentis® (ranibizumab) request form (PDF)
- Entyvio® (vedolizumab) request form (PDF)
- Evenity® (romosozumab) request form (PDF)
- Fabrazyme® (agalsidase beta) request form (PDF)
- Fasenra® (benralizumab) request form (PDF)
- Gaucher disease medication request form (PDF)
- Givlaari® (givosiran) request form (PDF)
- Hemlibra® (emicizumab-kxwh) request form (PDF)
- Hyaluronic acid intra-articular injections request form (PDF)
- Ilaris® (canakinumab) request form (PDF)
- Ilumya™ (tildrakizumab-asmn) request form (PDF)
- Immune globulin replacement therapy request form (PDF)
- Kanuma® (sebelipase alfa) request form (PDF)
- Krystexxa® (pegloticase) request form (PDF)
- Luxturna® (voretigene neparvovec) request form (PDF)
- Macugen®(pegaptanib) request form (PDF)
- Mucopolysaccharidoses (MPS) request form (PDF)
- Nplate® (romiplostim) request form (PDF)
- Nucala® (mepolizumab) request form (PDF)
- Onpattro® (patisiran) request form (PDF)
- Orencia® (abatacept) request form (PDF)
- Pompe disease medication request form (PDF)
- Prolia® (denosumab) request form (PDF)
- Pulmonary Arterial Hypertension (PAH) agents medication request form (PDF)
- Radicava® (Edaravone) request form (PDF)
- Reblozyl® (luspatercept-aamt) request form (PDF)
- Remicade® (infliximab) request form (PDF)
- Roctavian™ (valoctocogene-roxaparvovec) request form (PDF)
- Scenesse® (afamelanotide) request form (PDF)
- Simponi Aria® (golimumab) request form (PDF)
- Skyrizi™ (risankizumab-rzaa) request form (PDF)
- Soliris® (eculizumab) request form (PDF)
- Spinraza® (nusinersen) request form (PDF)
- Spravato™ (esketamine) request form (PDF)
- Stelara® (ustekinumab) request form (PDF)
- Tegsedi™ (inotersen) request form (PDF)
- Tepezza™ (teprotumumab) request form (PDF)
- Trogarzo™ (ibalizumab-uiyk) request form (PDF)
- Ultomiris™ (ravulizumab) request form (PDF)
- Uplizna™ (inebilizumab-cdon) request form (PDF)
- Vyepti™ (eptinezumab) request form (PDF)
- Xiaflex® (collagenase clostridium histolyticum) request form (PDF)
- Xolair® (omalizumab) request form (PDF)
- Zilretta® (triamcinolone acetonice extended release injectable) request form (PDF)
- Zinplava™ (Bezlotoxumab) request form (PDF)
- Zolgensma® (onasemnogene abeparvovec) request form (PDF)