Health Plans

For medications dispensed by pharmacies, please use the appropriate prescription drug plan prior authorization request form.

Many of our health plans have prior authorization programs for select medications*. For medications supplied, billed and administered in a physician's office or outpatient facility, we require prior approval for some medications for all insured groups. We also require prior approval for BlueCross BlueShield of South Carolina employees and their dependents who we cover with our health plan. (These health plan prior authorization requirements do not apply to State Health Plan or Federal Employee Program members.)

Here are the health plan prior authorization forms:

Acthar Gel Advate Alphanate  Alphanine
Bebulin Benefix Botox Carimune NF
CytoGam Euflexxa Feiba VH NF Flebogamma
Gamastan  Gammagard Liquid Gammagard SD Gammaplex
Gamunex  Helixate Hizentra Humate
Hyalgan  Koate Krystexxa Monarc-M 
Monoclate Mononine Novoseven Octagam
Orencia Orthovisc Privigen Profilinine
Rho (D) Recombinate Refacto Remicade
Rituxan Sandostatin Soliris Stimate
Supartz Synagis Synvisc Synvisc One
Wilate Tysabri Xyntha            Xolair

*These medication names may be the registered or unregistered trademarks of independent third-party pharmaceutical companies. These trademarks are included for informational purposes only and are not intended to imply or suggest any third-party affiliation.