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Most prescription drugs are limited to a maximum quantity in a single prescription. Log in to myWellmark to check your benefits to see if a drug is covered. 

  • Drugs indicated as non-formulary cannot be approved through the prior authorization process.
  • Your doctor can request approval using the Global Prior Authorization FormExternal Site. Obtaining the approval in advance will help to prevent delays at the pharmacy.
  • If the drug is approved, the prescription can be filled at any in-network pharmacy.

In addition, coverage for certain drugs is limited to specific quantities per month, benefit year, or lifetime. Amounts in excess of quantity limitations are not covered unless there is prior authorization criteria in place to request additional quantities and approval is granted. Your benefits certificate, coverage manual, or policy has specific information about your plan's prior authorization requirements.

Abstral
Acanya
Aciphex Sprinkles
Actemra
Acticlate
Actiq
Aczone
Adapalene 0.3%
Adcirca
Adderall XR
Adempas
Adoxa
Aerospan
Afrezza
Alsuma
Alvesco
Ambien CR
Amphetamine-Dextroamphetamine ER
Androderm
Androgel
Androgel Pump
Apidra
Aptensio XR
Armodafanil
Atralin
Aubagio
Avita
Avinza
Avonex
Axiron
Banzel
Beconase AQ
Belsomra
Benzaclin
Benzoyl Peroxide/Clindamycin
Berinert
Betaseron
Bivigam
Botox
Breo Ellipta
Brintellix
Butrans
Carac Cream
Carimune NF
Cialis
Cimzia
Cinryze
Cinqair
Clindamycin Foam
Clonidine ER
Concerta
Condylox Gel
Copaxone
Cosentyx
Daklinza
Daytrana
Desvenlafaxine ER
Desvenlafaxine Fumarate ER
Dexedrine
Dexilant
Dexmethylphenidate ER
Dextroamphetamine ER
Diclofenac Sodium 3% Gel
Differin 0.3%
Doryx
Doxycycline delayed release
Duac
Duragesic
Dymista
Dysport
Edluar
Embeda
Enbrel
Entresto
Entyvio
Epiduo Forte
Epoprostenol
Esbriet
Esomeprazole Strontium
Eszopiclone
Euflexxa
Evoclin
Exalgo
Extavia
Fentanyl Lozenge
Fentanyl transdermal system
Fentora
Fetzima
Firazyr
Flebogamma
Flolan
Flovent
Flunisolide Nasal Solution
Fluoroplex
Fluorouracil 0.5% Cream
Fluvoxamine Maleate ER
Focalin XR
Fortesta
Frova
Gammagard
Gammaked
Gammaplex
Gamunex C
Gel-One
Genotropin
Gilenya
Glatopa
Glucose Test Strips
Grastek
H.P. Acthar
Harvoni
Hetlioz
Hizentra
Humalog
Humalog Mix 50/50
Humalog Mix 75/25
Humatrope
Humira
Humulin 70/30
Humulin N
Humulin R-100
Hyalgan
Hyqvia
Hysingla ER
Intermezzo
Itraconazole
Jublia
Juxtapid
Kadian
Kalbitor
Kalydeco
Kapvay
Kazano
Kerydin
Khedezla
Kineret
Kombiglyze ER
Kuvan
Kynamro
Lemtrada
Letairis
Levitra
Lunesta
Luvox CR
Makena
Metadate CD
Metadate ER
Methylphenidate CD
Methylphenidate ER
Minocycline ER
Mirapex ER
Modafinil
Mometasone Nasal Spray
Monovisc
Morphine extended-release
Morphine extended-release beads
Movantik
MS Contin
Myobloc
Nasonex
Natesto
Nesina
Neuac
Nexium Capsules
Nexium Packets
Norditropin
Nucala
Nucynta ER
Nutropin
Nutropin AQ
Nuvigil
Octagam
Ofev
Olysio
Omnaris
Omnitrope
Onexton
Onfi
Onglyza
Onmel
Onsolis
Opana ER
Opsumit
Oracea
Oralair
Orencia
Orenitram
Orthovisc
Orkambi
Oseni
Otezla
OxyContin
Oxymorphone extended-release
Pegasys
Peg-Intron
Pexeva
Picato
Plegridy
Praluent
Prevacid Solutabs
Prilosec Packets
Pristiq
Privigen
Promacta
Protonix Packets
Proventil HFA
Provigil
Pulmicort Flexhaler
Qnasl
Qnasl Child
Quillivant XR
Ragwitek
Raloxifene
Rebif
Relistor
Relpax
Remicade
Remodulin
Repatha
Requip XL
Retin A Micro
Retin-A
Revatio
Rexulti
Ritalin LA
Rituxan
Ropinirole ER
Rozerem
Ruconest
Saizen
Savaysa
Serostim
Sildenafil
Silenor
Simponi
Simponi Aria
Solaraze
Solodyn
Sovaldi
Sporanox
Staxyn
Stelara
Stendra
Strattera
Strensiq
Striant
Subsys
Sumavel Dosepro
Supartz
Symbicort
Synagis
Synvisc
Synvisc-One
Tamoxifen
Tanzeum
Tecfidera
Technivie
Testim
Testosterone Gel 1%
Testosterone Gel Pump 1%
Tracleer
Tretinoin Micronized topical
Tretinoin topical
Treximet
Trulicity
Tysabri
Tyvaso
Uloric
Uptravi
Veletri
Veltin
Ventavis
Ventolin HFA
Veramyst
Veregen Ointment
Viagra
Viekira Pak
Viekira XR
Viibryd
Vogelxo
Vraylar
Vyvanse
Xartemis XR
Xeljanz
Xeomin
Xolair
Xopenex HFA
Xtampza
Xyrem
Zecuity
Zepatier
Zetonna
Ziana
Zohydro ER
Zolpidem Tartrate ER
Zolpimist
Zomacton
Zomig Nasal Spray
Zorbtive
Zurampic
Zyclara