Drugs Requiring Preauthorization

Helping keep costs down and getting the most appropriate treatment.

The WEA Trust requires preauthorization for certain prescription drugs. Depending on the drug, either MedImpact or Coram Specialty Infusion Services will handle preauthorization. The sections below detail which drugs are handled by which company.

Questions About Drug Preauthorization?

WEA Trust: 800-279-4000
Coram: 888-439-3661
MedImpact: 888-807-8106

Q:Managed By MedImpact

The list below contains the most common prescription drugs requiring preauthorization. For a complete list, please reference our Preferred Drug List.

Most common prescription drugs requiring preauthorization:

Adapalene (over age 25)
Androgel
Aripiprazole
Copaxone
Crestor
Dextroamphetamine-amphetamine (quantity limit)
Dextroamphetamine-amphetamine ER (over age 18)
Elidel
Enbrel
Enoxaparin Sodium
Fentanyl
Gleevac
Harvoni
Humira
Imiquimod
Jublia

Latuda
Methylphenidate ER (over age 18)
Modafinil
Neulasta
Nexium
Nuvaring
Nuvigil
Pristiq ER
Sovaldi
Subuxone
Tecfidera
Tretinoin (over age 25)
Vancomycin
Vesicare
Vyvanse
Xyrem
Zolpidem tartrate ER

Q:Managed By WEA Trust

Drug Name	Generic Name	Preauthorization Form
Actemra	Tocilizumab	Actemra Preauthorization Form
ACTHAR HP		ACTHAR HP Preauthorization Form
Antiarrythmic Drug BetaPace Induction		Antiarrhythmic Preauthorization Form
Antihemophilic factors	Factors VII/IX	Factor IX Preauthorization Form
Botox	Botulinum Toxinox	Botox Preauthorization Form
Entyvio	Vedolizumab	Entyvio Preauthorization Form
Epoetin	Epogen/Procrit	Epogen Preauthorization Form
Factor VIII		Factor VIII Preauthorization Form
Factor IX	Alprolix	Factor IX Preauthorization Form
Fasenra	Benralizumab	Fasenra Preauthorization Form
Hemlibra		Hemlibra Preauthorization Form
Infliximab		Infliximab Preauthorization Form
Interferon and Peginterferon for Hepatitis B		Interferon-Peginterferon Preauthorization Form
Lupron	Lueprolide	Lupron Preauthorization Form
Lemtrada	Alemtuzumab	Lemtrada Preauthorization Form
Nucala	Mepolizumab	Nucala Preauthorization Form
Ocrevus	Orelizumab	Ocrevus Preauthorization Form
Orencia	Abatacept	Orencia Preauthorization Form
Oncology Coverage Policy		Oncology Coverage Policy
Prolia	Denosumab	Prolia Preauthorization Form
Reclast/Zometa	Zoledronic acid	Reclast-Zometa Preauthorization Form
Remicade	Infliximab	Remicade Preauthorization Form
Rituxan	Rituximab	Rituxan Preauthorization Form
Simponi Aria	Golimumab	Simponi Aria Preauthorization Form
Soliris	Eculizumab	Soliris Preauthorization Form
Stelara	Ustekinumab	Stelara Preauthorization Form
Sublocade	Buprenorphine Extended‐Release Injection	Sublocade Preauthorization Form
Vivitrol	Naltrexone	Vivitrol Preauthorization Form
Xolair	Omalizumab	Xolair Preauthorization Form

Q:Managed By Coram

Drug Name	Generic Name	Code
Aldurazyme	Laronidase	J1931
Aralast		J0256
Bivigam		J1556
Carimune		J1566
Ceredase	Alglucerase	J0205
Cerezyme	Imiglucerase	J1786
Elaprase	Idursulfase	J1743
Fabrazyme	Algalsidase	J0180
Flebogamma		J1572
Gamastan S/D		J1460
Gammagard Liquid		J1569
Gammagard S/D		J1566
Gammaked		J1561
Gammaplex		J1557
Gamunex		J1561
Gamunex C		J1602
Glassia		J0256
Hizentra		J1559
Lumizyme	Alglucosidase	J0221
Myozyme	Alglucosiderase	J0220
Naglazyme	Galsulfase	J1458
Octagam		J1568
Privigen		J1459
Vpriv	Valaglucerase	J3385
Zemaira	Alpha 1 Proteinase	J0256

Customer Service

800-279-4000

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Customer Service

Drugs Requiring Preauthorization

Helping keep costs down and getting the most appropriate treatment.

Questions About Drug Preauthorization?

Q:Managed By MedImpact

Most common prescription drugs requiring preauthorization:

Q:Managed By WEA Trust

Drug Name

Generic Name

Preauthorization Form

Q:Managed By Coram

Drug Name

Generic Name

Code

Customer Service

800-279-4000