Part B Versus D Drugs (Platino)

General Prior Authorization Request Form

PRODUCT NAME ROUTE / DOSAGE FORM / STRENGTH
ACETYLCYSTEINE ACETYLCYSTEINE INHAL 10 %, 20 %
ALBUTEROL ALBUTEROL NEB 0.083 %, 0.5 %
AMIKACIN AMIKACIN INJ 250 MG/ML, 50 MG/ML
AMINO ACID & DEXTROSE AMINOSYN, CLINIMIX,  TRAVASOL INJ
AMINO ACID & ELECTROLYTE & DEXTROSE AMINOSYN, CLINIMIX E, TRAVASOL INJ
AMINO ACIDS AMINESS, AMINOSYN, CLINIMIX, NEPHRAMINE, RENAMIN, TRAVASOL, TROPHAMINE INJ
AMINO ACIDS & ELECTROLYTE AMINOSYN, PROCALAMINE INJ
AMINOPHYLLINE AMINOPHYLLINE INJ 25 MG/ML
AMPICILLIN & SULBACTAM AMPICILLIN-SULBACTAM INJ 2-1 GM
AMPICILLIN SODIUM AMPICILLIN SODIUM INJ 1 GM
ARIPIPRAZOLE ABILIFY INJ 9.75 MG/1.3ML
AZATHIOPRINE AZATHIOPRINE TABS 50 MG; INJ 100 MG
BUDESONIDE PULMICORT INHAL 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML
BUMETANIDE BUMETANIDE INJ 0.25 MG/ML
CAPREOMYCIN CAPASTAT INJ 1 GM
CEFAZOLIN CEFAZOLIN INJ 1 GM, 500 MG
CEFEPIME CEFEPIME INJ 1 GM, 2 GM
CEFOTAXIME CEFOTAXIME INJ 1 GM, 2 GM, 500 MG
CEFTAZIDIME CEFTAZIDIME INJ 1 GM, 2 GM
CEFTRIAXONE CEFTRIAXONE INJ 250 MG, 500 MG
CEFUROXIME SODIUM CEFUROXIME SODIUM INJ 1.5 GM, 750 MG
CIMETIDINE CIMETIDINE INJ 150 MG/ML
CIPROFLOXACIN CIPROFLOXACIN INJ 1 %
CLINDAMYCIN CLINDAMYCIN INJ 150 MG/ML
COLISTIMETHATE COLISTIMETHATE INJ 150 MG
CROMOLYN CROMOLYN NEB 20 MG/2ML
CYCLOSPORINE CYCLOSPORINE CAPS 100 MG, 25 MG; INJ 50 MG/ML
CYCLOSPORINE MODIFIED CYCLOSPORINE MODIFIED CAPS 100 MG, 50 MG; SOLN 100 MG/ML
DAPTOMYCIN CUBICIN INJ 500 MG
DEXTROSE DEXTROSE INJ
DEXTROSE & SODIUM CHLORIDE DEXTROSE/SODIUM CHLORIDE INJ
DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE INJ 100 MG
ELECTROLYTES ELECTROLYTES, ISOLYTE, NORMOSOL, PLASMA-LYTE INJ
ERTAPENEM INVANZ INJ 1 GM
ERYTHROMYCIN LACTOBIONATE ERYTHROMYCIN LACTOBIONATE INJ 500 MG
FAMOTIDINE FAMOTIDINE INJ 10 MG/ML
FAT EMULSION INTRALIPID INJ
FLUCONAZOLE & DEXTROSE FLUCONAZOLE/DEXTROSE INJ
FLUCONAZOLE & SODIUM CHLORIDE FLUCONAZOLE/SODIUM CHLORIDE INJ
GENTAMICIN GENTAMICIN INJ 10 MG/ML, 40 MG/ML
GLOBULIN, IMMUNE POLYGAM INJ 10 GM
LEVETIRACETAM KEPPRA INJ 500 MG/5ML
LINCOMYCIN LINCOCIN INJ 300 MG/ML
METHOCARBAMOL ROBAXIN INJ 100 MG/ML
METHOTREXATE METHOTREXATE INJ 1 GM, 25 MG/ML
METHYLPREDNISOLONE ACETATE DEPO-MEDROL INJ 20 MG/ML
METHYLPREDNISOLONE ACETATE INJ 40 MG/ML, 80 MG/ML
METHYLPREDNISOLONE SODIUM SUCCINATE METHYLPREDNISOLONE SODIUM SUCCINATE INJ 125 MG, 40 MG
MITOXANTRONE MITOXANTRONE INJ 2 MG/ML
MYCOPHENOLATE MOFETIL CELLCEPT SUSP 200 MG/ML; INJ 500 MG
MYCOPHENOLATE MOFETIL CAPS 250 MG; TABS 500 MG
MYCOPHENOLATE SODIUM MYFORTIC TABS 180 MG, 360 MG
NAFCILLIN SODIUM NAFCILLIN SODIUM INJ 1GM
NALOXONE NALOXONE INJ 0.4 MG/ML, 1 MG/ML
ONDANSETRON ONDANSETRON INJ 2 MG/ML
OXACILLIN SODIUM OXACILLIN SODIUM INJ 1 GM
PANTOPRAZOLE PROTONIX INJ 40 MG
PENICILLIN G PROCAINE PENICILLIN G PROCAINE INJ 600000 U/ML
PENTAMIDINE NEBUPENT NEB 300 MG
PENTAM INJ 300 MG
PHENYTOIN PHENYTOIN INJ 50 MG/ML
PIPERACILLIN & TAZOBACTAM ZOSYN INJ 3-0.375 GM
POTASSIUM CHLORIDE POTASSIUM CHLORIDE INJ 2 MEQ/ML
POTASSIUM CHLORIDE & DEXTROSE& LACTATE RINGERS POTASSIUM CHLORIDE & DEXTROSE& LACTATE RINGERS INJ
POTASSIUM CLAVULANATE & TICARCILLIN TIMENTIN INJ 3.1 GM
RANITIDINE RANITIDINE INJ 25 MG/ML
SIROLIMUS RAPAMUNE SOLN 1 MG/ML; TABS 1 MG , 2 MG
SODIUM CHLORIDE SODIUM CHLORIDE 0.45 %, 0.9 %; INJ 2.5 MEQ/ML; IRRIGATION SOLN 0.9 %
SULFAMETHOXAZOLE & TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM INJ 400-80 MG/5ML
TACROLIMUS PROGRAF CAPS 0.5 MG, 1 MG, 5 MG; INJ 5 MG/ML
TETANUS TOXOID ADSORBED TETANUS TOXOID ADSORBED INJ 5 LFU
TIGECYCLINE TYGACIL INJ 50 MG
TOBRAMYCIN TOBRAMYCIN INJ 10 MG/ML, 40 MG/ML
TRANEXAMIC ACID CYKLOKAPRON INJ 100 MG/ML
VALPROATE SODIUM VALPROATE SODIUM INJ 100 MG/ML
VANCOMYCIN VANCOMYCIN INJ 1000 MG
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