USFHP Prior Authorization Forms

A

Abilify Mycite
Absorica
Absorica LD
Acanya
Aciphex Generics
Actemra
Acthar
Acticlate
Actoplus Met
Actos
Aczone
Adapalene 0.1 Topical Solution
Adapalene 0.1 External Pad/Swab
Addyi
Adempas
Adipex-P 
Adlarity
Adlyxin
Adoxa
Aemcolo
Aerospan
Afrezza
Aimovig
AirDuo
Ajovy
Aklief
Alecensa
Allopurinol
Almotriptan
Altoprev
Alunbrig
Alvesco
Amcinonide Ointment
Amitiza
Amrix
Amzeeq
Androderm
Androgel
Antara
Aplenzin
Arakoda
Arikayce
Arnuity Ellipta
Asmanex 
Aspruzyo Sprinkles
Astepro
Austedo
Auvelity
Auvi-Q
Avandamet
Avandaryl
Avandia
Avidoxy Tablet
Avodart
Axiron
Ayvakit
Azelex (Azelaic Acid)
Azesco
Azor

B

Bafiertam
Balversa
Basaglar
Beconase AQ
Belsomra
Belviq
BelviqXR
Benicar
Benicar HCT
Benlysta
Benzphetamine
Bepreve
Binosto
Bonjesta
Braftovi
Bravelle
Breo Ellipta
Brukinsa
Butrans
Bydureon
Bydureon Bcise
Byetta
Bystolic

C

Calquence 
Camcevi Kit
Camzyos 
Caplyta
Carospir
Cequa
Chlorzoxazone 250mg Tablets
Chlorzoxazone 375mg and 750mg
Cialis 
Cibinqo
Cimzia
Cinryze
Clindagel
Clobetasol propionate 0.05%
Compounded Medications
Continuous Glucose Monitoring Devices
Contrave
Copiktra
Cordran Tape
Coremino ER
Corlanor
Cosentyx
Cotellic
Cotempla XR ODT
Crotan Lotion
Cuvrior
Cyclobenzaprine 7.5mg
Cycloset

D

Dabigatran Capsules
Dapsone Products
Daurismo
Dayvigo
Denavir
Desoximetasone 0.05% Gel
Desvelafaxine ER
Detrol
Dexcom G6 Devices (CGM)
Diclegis
Diclofenac Gel 3% (Solaraze)
Didrex
Diethylpropion
Diflorasone Diacetate 0.05% Cream
Diflorasone Diacetate 0.05% Ointment
Dojolvi
Doptelet
Doryx MPC
Doryx/Doxycycline Hyclate
Doxycycline Monohydrate 40mg IR/DR
Drizalma Sprinkle
Duetact
Duexis
Dulera
Dupixent
Dymista

E

Edarbi
Edarbyclor
Edluar
Emadine
Emflaza
Emgality 100mg
Emgality 120mg
Enablex
Enbrel
Endari
Enspryng
Entresto
Epclusa
Epidiolex
Epiduo
Epiduo Forte
Epogen
Erleada
Ermeza
Esbriet
Eucrisa
Eurax
Evekeo ODT
Evrysdi
Ezallor Sprinkle

F

Farxiga
Farydak
Fasenra Pen
Fertility Agents
Fertinex
Fetzima
Fiasp
Fibric Acid Derivatives
Fibricor
Finacea
Fintepla
Firdapse
FloLipid
Follistim
Fortamet
Forteo
Fortesta
Fosamax Plus D
Fravatriptan
Freestyle Libre 2 Devices (CGM)
Freestyle Libre 3 Devices (CGM)
Fycompa O/S
Fylnetra

G

Galafold
Gavreto
Gelnique 
Gemtesa
Generess FE
Generic Advair Diskus
Generic Insulin Aspart
Generic Sildenafil Tablets
Generic Tadalafil Tablets
Genotropin
Gilenya
Gloperba
Glucose Test Strips
Glyxambi
Gocovri
Gonal-F
Gralise

H

Haegarda
Harvoni
Hemlibra
Hetlioz
Horizant
Humalog
Humatrope
Humegon
Humira 
Hyftor

I

Ibrance
Idhifa
Ilumya
Imbruvica 
Imcivree
Imvexxy
Inbrija
Increlex
Ingrezza
Inhaled Corticosteroids
Inpefa
Inqovi
Inrebic 
Insulin Glargine Solostar
Insulin Lispro Vial & KwikPen
Intermezzo
Intrarosa
Invokamet
Invokana
Isturisa

J

Jalyn
Janumet XR
Januvia
Jardiance
Jatenzo
Jentadueto
Joenja
Jornay PM
Jublia
Jynarque

K

Kalydeco
Kapspargo Sprinkle
Kazano
Kerydin
Kesimpta
Keveyis
Kevzara
Khedezla
Kineret
Kisqali
Kisqali Femara
Kombiglyze XR
Koselugo

L

Lastacaft
Lescol XL
Letairis
Leuprolide acetate depot IM 22.5 mg vial
Levemir
Levitra
Licart
Lidocaine-Tetracaine 7%-7% Cream
Linzess
Lipofen
Livalo
Liqrev
Lomaira
Lonhala Magnair
Lorbrena
Lovaza
Lucemyra
Lumryz
Lupron Depot
Lynparza
Lyrica
Lytgobi
Lyumjev
Lyvispah

M

Mavenclad
Mavyret
Mayzent
Mefloquine
Mekinist
Mektovi
Menopur
Mesalamine (Generic Lialda) 
Metformin IR 625 mg
Methocarbamol
Miebo
Mifeprex
Minastrin FE Chewable
Minocin
Minocycline ER Generic
Minolira ER
Mirvaso
Monodoxyne NL
Monodox
Morgidox
Motegrity 
Mounjaro
Movantik
Mulpleta
Mycapssa
Mydayis 
Myfembree
Myrbetriq 
Mybetriq Granules

N

Namenda XR
Namzaric
Naprelan/Generics
Naratriptan
Nasal Allergy Drugs
Nasonex
Natesto
Nerlynx
Nesina
Neupogen
Neupro Patch
Nexium/Generics
Nexletol
Nexlizet
Nilandron
Ninlaro
Nocdurna
Noctiva
Norditropin FlexPro
Noritate 
Norliqva
Northera
Nourianz
Nubeqa
Nucala
Nucynta ER
Nuplazid
Nurtec ODT
Nutropin AQ

O

Ocaliva
Odactra
Ofev
Okebo
Olumiant
Olysio
Omnaris
Omnitrope 
Omnipod Classic Pods (Gen 3)
Omnipod Dash Pods (Gen 4)
Omnipod 5 Kits and Pods
Onextron
Onglyza
Onureg
Opsumit
Opzelura
Oracea
Oral Bisphosphonates
Oral Triptans
Orencia SC
Orenitram ER
Orgovyx
Oriahnn
Orilissa
Orkambi
Oseni
Osmolex ER
Otezla
Otrexup
Oxbryta
Oxervate 
Oxycodone 2.5-, 5-, 7.5-, and 10 mg/Acetaminophen 300 mg tablet
Oxycodone 10 mg/Acetaminophen 300 mg/5 mL oral solution
Oxytrol
Ozempic
Ozobax

P

Palforzia
Palynziq
Pancreaze
Pataday
Patanase
Pemazyre
Pennsaid
Pergonal
Pertzye 
Pexeva
Phendimetrazine IR & SR
Phentermine
Phexxi
Phospholine
Piqray
Pomalyst
Praluent
Prestalia
Prevacid
Pristiq
Procrit
Prograf Granule Packet
Pulmicort Flexhaler

Q

Qbrexza 
Qelbree
Qinlock
Qmiiz ODT
Qnasl
Qsymia
Qtern
Qualaquin
Qudexy XR
Qulipta
Quviviq
Qvar

R

Radicava ORS
Rapaflo
Rasuvo
Rayos
Releuko
Relistor
Relyvrio
Repatha
Repronex
Restasis
Retevmo
Retin A Micro
Revlimid
Rexulti
Reyvow
Rezlidhia
Rhinocort Aqua
Rhofade
Rhopressa
Rinvoq ER
Rocklatan
Rozerem
Rozlytrek
Rubraca
Ruzurgi
Rybelsus
Rydapt
Rytary

S

Saizen
Sanctura XR
Savella
Saxenda
Segluromet
Semglee Pen
Serostim
Seysara
Siklos
Silenor
Siliq
Simponi
Sitavig
Skyclarys
Skyrizi
Soliqua
Solodyn ER
Somatropin
Soolantra 
Sogroya
Sotyktu
Sovaldi 
Spiriva HandiHaler
Staxyn
Steglatro
Steglujan
Stelara
Stendra
Strensiq
Striant
Sunosi
Symbicort
Symdeko
Symlin
Symproic
Syndros
Synjardy

T

Tabrecta 
Tadliq
Tafinlar
Takhzyro
Taltz
Talzenna
Targadox 
Tarpeyo
Tascenso
Tavalisse
Tavneos
Tazverik
Tecfidera
Technivie
Tegsedi
Tekturna
Tekturna HCT
Teriparatide
Testim
Testosterone 1% & 1.62% Gel 
Testosterone Cypionate and Enanthate IM injections
Thiazolidinediones (TZDs)
Thiola
Thiola EC
Tibsovo
Tiglutik
Tirosint-SOL
Tivorbex 
Tlando
Tolsura
Topical Antibiotics and Combinations
Topical Metronidazole Products
Topical Retinoids and Combinations
Toujeo
Toviaz
Tracleer/Generic
Tradjenta
Tremfya
Tresiba
Treximet
Tribenzor
Triglide
Trijardy XR
Trikafta
Trilipix
Trintellix
Trokendi XR
Trulance
Trulicity
Tukysa
Turalio
Twirla
Tymlos
Tyvaso

U

Ubrelvy
Uloric
Upneeq
Uptravi

V

Valsartan
Vascepa
Veltin
Venclexta 
Venlafaxine Besylate 
Ventavis
Veozah
Verkazia
Verzenio
Vesicare
V-Go
Viagra
Viberzi
Vibramycin
Victoza
Viekira Pak
Viekira XR 
Vijoice
Viokace
Vitrakvi
Vivlodex 
Vivjoa
Vizimpro
Vogelxo
Vosevi 
Voquezna Dual Pak
Voquezna Triple Pak

Vowst
Vtama
Vumerity
Vyleesi
Vyndamax
Vyndaqel
Vytorin
Vyvanse
Vyzulta

W

Wakix
Wegovy
Winlevi
Wixela

X

Xadago
Xalkori
Xatmep
Xatmep Oral Solution
Xeljanz
Xeljanz XR
Xelstrym
Xenical
Xepi
Xerese
Xermelo
Xhance
Xifaxan 200mg
Xifaxan 550mg
Xigduo XR
Xiidra
Ximino ER
Xospata
Xpovio
Xtandi
Xultophy
Xuriden
Xyosted
Xyrem
Xywav

Y

Yonsa
Yupelri

Z

Zalvit
Zarxio
Zavzpret
Zegerid
Zejula
Zelboraf
Zembrace Injection
Zenpep
Zepatier
Zeposia
Zerviate
Zetonna
Ziana
Zilxi
Zipsor
Zolpidem Tartrate Capsule
Zolpimist
Zomacton
Zomig Nasal 
Zonisade
Zorbtive
Zorvolex 
Zoryve 
Ztalmy
ZTLido 
Zydelig
Zypitamag
Zytiga 250mg
Zytiga 500mg