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The following medications require prior authorization.
Please call MedImpact at 1-800-788-2949 to request a prior authorization form.
| Brand Name | Generic Name |
| 8-MOP | methoxsalen |
| Accutane | isotretinoin |
| Actimmune | interferon gamma 1B |
| Alferon N | interferon alfa-N3 |
| Ambiem CR | zolpidem extended release |
| Amevive | alefacept |
| Aranesp | darbepoetin |
| Avinza | morhine sulfate extended release |
| Avonex | interferon beta 1A |
| Betaseron | interferon beta 1B |
| Copaxone | glatiramer acetate |
| Eligard | leuprolide acetate |
| Enbrel | etanercept |
| Epogen | epoetin alfa |
| Genotropin | somatropin |
| Humatrope | somatropin |
| Humira | adalimumab |
| Infergen | interferon alfacon-1 |
| Intron A | interferon alfa 2B |
| Iressa | gefitinib |
| Kineret | anakinra |
| Leukine | sargramostin |
| Lunesta | eszopiclone |
| Lupron/Lupron Depot/ Lupron Depot-Ped | leuprolide acetate |
| Neulasta | pegfilgrastim |
| Neumega | oprelvekin |
| Neupogen | filgrastim |
| Norditropin | somatropin |
| Nutropin/Nutropin AQ / Nutropin Depot | somatropin |
| Oxsoralen-Ultra | methoxalen rapid |
| Pegasys | peg-interferon alfa 2A |
| Peg-Intron | peg-interferon alfa 2B |
| Procrit | epoetin alfa |
| Protropin | somatrem |
| Prozac Weekly | fluoxetine (weekly) |
| Raptiva | eflazumab |
| Rebetron | interferon alfa-2B/ribavirin |
| Rebif | intereferon beta 1A |
| Regranex | becaplermin |
| Remicade | infliximab |
| Roferon | interferon alfa |
| Rozerem | ramelteon |
| Saizen | somatropin |
| Serostim | somatropin |
| Somavert | pegvisomant |
| Soriatane / Soriatane CK | acitretin |
| Sotret | isotretinoin |
| Synagis | pavlivizumab |
| Synarel | nafarelin |
| Tev-Tropin | somatropin |
| Xanax XR | alprazolam |
| Xolair | omalizumab |
| Zorbtive | somatropin |