Medical and Drug Authorizations
Use the medical authorization table and the drug prior authorization list to learn whether an authorization is required or search out-of-area medical authorizations.
Medical authorizations
The medical authorization table provides the medical policies and criteria used by Wellmark and is the first stop in learning whether an authorization is required.
Be sure to obtain approval in advance to help prevent delays and unexpected costs.
View Authorization Table Search Out-of-Area AuthorizationsDrug authorizations
Some drugs, and certain amounts of some drugs, require an approval before they are eligible for coverage. The drugs listed below require prior authorization.
Click the drug name or policy name to view the clinical criteria.
View drug list Submit a Drug Authorization Secure SiteDrug authorization & quantity limits
To search more quickly, use the keyboard shortcut: CTRL+F (PC) or Command-F (Mac)
View opioid-related drugs
View Drugs for Weight Loss Management policy PDF File
Policies starting with A
- Abecma PDF File
- Acanya PDF File
- Aciphex PDF File
- Aciphex Sprinkles PDF File
- Actemra PDF File
- Aczone PDF File
- Adakveo PDF File
- Adapalene 0.3% PDF File
- Adapalene/Benzoyl Peroxide PDF File
- Adbry PDF File
- Adcirca PDF File
- Adderall XR PDF File
- Addyi PDF File
- Adempas PDF File
- Adlyxin PDF File
- Admelog PDF File
- Adzensys XR-ODT PDF File
- Afrezza PDF File
- Aimovig PDF File
- AirDuo (BRAND ONLY) PDF File
- Ajovy PDF File
- Aklief PDF File
- Aldurazyme PDF File
- Alinia PDF File
- Alkindi Sprinkles PDF File
- Almotriptan PDF File
- Alrex PDF File
- Altreno PDF File
- Alvesco PDF File
- Alyq PDF File
- Ambrisentan PDF File
- Amitiza (BRAND ONLY) PDF File
- Amjevita PDF File
- Amphetamine-Dextroamphetamine ER PDF File
- Amphetamine ER PDF File
- Amphetamine sulfate PDF File
- Amvuttra PDF File
- Amzeeq PDF File
- Anastrazole PDF File
- Androderm PDF File
- Androgel PDF File
- Androgel Pump PDF File
- Apidra PDF File
- Aptensio XR PDF File
- Aralast NP PDF File
- Arazlo PDF File
- Aripiprazole oral solution PDF File
- Armodafinil PDF File
- ArmonAir PDF File
- Asceniv PDF File
- Aspruzyo Sprinkle PDF File
- Atralin PDF File
- Aubagio PDF File
- Austedo PDF File
- Avastin PDF File
- Avita PDF File
- Avonex PDF File
- Avsola PDF File
- Axert PDF File
- Azelastine/fluticasone nasal spray PDF File
- Azelex PDF File
- Azstarys PDF File
Policies starting with B
- Baclofen oral solution PDF File
- Bafiertam PDF File
- Banzel PDF File
- Baraclude solution PDF File
- Bebtelovimab PDF File
- Beconase AQ PDF File
- Belsomra PDF File
- Benzaclin PDF File
- Benzoyl Peroxide/Clindamycin PDF File
- Berinert PDF File
- Besremi PDF File
- Betaseron PDF File
- Bevacizumab PDF File
- Bivigam PDF File
- Bosentan PDF File
- Botox PDF File
- Breyanzi PDF File
- Breztri Aerosphere PDF File
- Brineura PDF File
- Bronchitol PDF File
- Budesonide/Formoterol Fumarate Inhalation PDF File
- Bydureon BCise PDF File
- Byetta PDF File
- Bylvay PDF File
Policies starting with C
- Camzyos PDF File
- Caplyta PDF File
- Carac Cream PDF File
- Carimune NF PDF File
- Carospir PDF File
- Cerdelga PDF File
- Cerezyme PDF File
- Cequa PDF File
- Cibinqo PDF File
- Cimzia PDF File
- Cinryze PDF File
- Cinqair PDF File
- Citalopram oral solution PDF File
- Clindamycin Foam PDF File
- Clindamycin phosphate/tretinoin topical PDF File
- Clobazam PDF File
- Compounded Drug Products PDF File
- Concerta PDF File
- Condylox Gel PDF File
- Copaxone PDF File
- Corlanor PDF File
- Cosentyx PDF File
- Cotempla XR PDF File
- Crysvita PDF File
- Cutaquig PDF File
- Cuvitru PDF File
- Cuvposa PDF File
Policies starting with D
- Dapsone topical gel PDF File
- Dartisla ODT PDF File
- Daytrana PDF File
- Dayvigo PDF File
- Desvenlafaxine ER PDF File
- Desvenlafaxine Fumarate ER PDF File
- Dexedrine PDF File
- Dexilant PDF File
- Dexlansoprazole PDF File
- Dexmethylphenidate ER PDF File
- Dextroamphetamine ER PDF File
- Diacomit PDF File
- Diclofenac epolamine patch PDF File
- Differin 0.3% PDF File
- Dificid Oral Suspension PDF File
- Dimethyl Fumarate PDF File
- Dojolvi PDF File
- Doptelet PDF File
- Doryx PDF File
- Doxepin (generic Silenor) PDF File
- Doxycycline delayed release PDF File
- Doxycycline Hyclate delayed release tablet PDF File
- Drizalma Sprinkles PDF File
- Duac PDF File
- Dulera PDF File
- Dupixent PDF File
- Durolane PDF File
- Dyanavel XR PDF File
- Dymista PDF File
- Dysport PDF File
Policies starting with E
- Edluar PDF File
- Elaprase PDF File
- Elelyso PDF File
- Eletriptan PDF File
- Elyxyb PDF File
- Emflaza PDF File
- Emgality PDF File
- Empaveli PDF File
- Enalapril oral solution PDF File
- Enbrel PDF File
- Enjaymo PDF File
- Enspryng PDF File
- Entresto PDF File
- Entyvio PDF File
- Epaned PDF File
- Epclusa PDF File
- Epidiolex PDF File
- Epiduo Forte PDF File
- Epogen PDF File
- Epoprostenol PDF File
- Eprontia PDF File
- Esbriet PDF File
- Esomeprazole Strontium PDF File
- Eucrisa PDF File
- Euflexxa PDF File
- Evekeo PDF File
- Evekeo ODT PDF File
- Evenity PDF File
- Evkeeza PDF File
- Evoclin PDF File
- Evrysdi PDF File
- Exemestane PDF File
- Extavia PDF File
- Eysuvis PDF File
Policies starting with F
- Fabior PDF File
- Fabrazyme PDF File
- Fasenra PDF File
- Fetzima PDF File
- Finacea 15% foam PDF File
- Fintepla PDF File
- Firazyr/Sajazir PDF File
- Firdapse PDF File
- Firvanq PDF File
- Flebogamma PDF File
- Flector PDF File
- Fleqsuvy PDF File
- Flolan PDF File
- FloLipid PDF File
- Flovent PDF File
- Flunisolide Nasal Solution PDF File
- Fluorouracil 0.5% Cream PDF File
- Fluorouracil topical PDF File
- Fluvoxamine Maleate ER PDF File
- Focalin XR PDF File
- Forteo PDF File
- Fortesta PDF File
- Frova PDF File
- Frovatriptan PDF File
- Fylnetra PDF File
Policies starting with G
- Galafold PDF File
- Gammagard PDF File
- Gammaked PDF File
- Gammaplex PDF File
- Gamunex C PDF File
- Gel-One PDF File
- Gelsyn-3 PDF File
- Genotropin PDF File
- Genvisc 850 PDF File
- Gilenya PDF File
- Givlaari PDF File
- Glassia PDF File
- Glatopa PDF File
- Gloperba PDF File
- Glucose Test Strips PDF File
- Glycopyrrolate oral solution PDF File
- Gocovri PDF File
- Granix PDF File
- Grastek PDF File
Policies starting with H
- Harvoni PDF File
- Haegarda PDF File
- Hemgenix PDF File
- Herceptin PDF File
- Hetlioz PDF File
- High dollar drug review policy PDF File
- Hizentra PDF File
- Humalog PDF File
- Humalog Mix 50/50 PDF File
- Humalog Mix 75/25 PDF File
- Humatrope PDF File
- Humira PDF File
- Humulin 70/30 PDF File
- Humulin N PDF File
- Humulin R-100 PDF File
- Hyalgan PDF File
- Hymovis PDF File
- Hyqvia PDF File
Policies starting with I
- Icatibant PDF File
- Ilumya PDF File
- Imcivree PDF File
- Imitrex injection PDF File
- Imiquimod Pump 3.75% cream PDF File
- Inbrija PDF File
- Increlex PDF File
- Indocin oral suspension PDF File
- Inflectra PDF File
- Ingrezza PDF File
- Interim Policy on New FDA Approvals PDF File
- Insulin Degludec PDF File
- Intermezzo PDF File
- Invokamet PDF File
- Invokamet XR PDF File
- Invokana PDF File
- Isturisa PDF File
- Itraconazole PDF File
- Ivermectin PDF File
Policies starting with J
Policies starting with K
- Kalbitor PDF File
- Kalydeco PDF File
- Kanuma PDF File
- Katerzia PDF File
- Kazano PDF File
- Kerydin PDF File
- Keytruda PDF File
- Kesimpta PDF File
- Kevzara PDF File
- Khedezla PDF File
- Kineret PDF File
- Klisyri PDF File
- Kombiglyze ER PDF File
- Korlym PDF File
- Koselugo PDF File
- Krystexxa PDF File
- Kymriah PDF File
- Kynmobi PDF File
Policies starting with L
- Lanreotide PDF File
- Lansoprazole PDF File
- Lantus PDF File
- Ledipasvir/sofosbuvir PDF File
- Lemtrada PDF File
- Leqvio PDF File
- Letairis PDF File
- Leukine PDF File
- Livmarli PDF File
- Lucemyra PDF File
- Lumizyme PDF File
- Lupkynis PDF File
- Luvox CR PDF File
- Luxturna PDF File
- Lybalvi PDF File
- Lyrica solution PDF File
- Lyumjev PDF File
- Lyvispah PDF File
Policies starting with M
- Mavenclad PDF File
- Mavyret PDF File
- Mayzent PDF File
- Memantine oral solution PDF File
- Mepsevii PDF File
- Metadate CD PDF File
- Metadate ER PDF File
- Metformin oral solution PDF File
- Methitest PDF File
- Methylphenidate CD PDF File
- Methylphenidate ER PDF File
- Methyltestosterone PDF File
- Miglustat PDF File
- Minocycline ER PDF File
- Mirapex ER PDF File
- Mircera PDF File
- Mirvaso PDF File
- Modafinil PDF File
- Mometasone Nasal Spray PDF File
- Monovisc PDF File
- Motegrity PDF File
- Movantik PDF File
- Mycapssa PDF File
- Mydayis PDF File
- Myfembree PDF File
- Myobloc PDF File
- Myrbetriq granules PDF File
Policies starting with N
- Naglazyme PDF File
- Namenda oral solution PDF File
- Naprosyn suspension PDF File
- Naproxen suspension PDF File
- Natesto PDF File
- Nayzilam PDF File
- Nesina PDF File
- Neuac PDF File
- Neulasta PDF File
- Neulasta Onpro PDF File
- Neupogen PDF File
- Neupro PDF File
- Nexium Capsules PDF File
- Nexium Packets PDF File
- Nexletol PDF File
- Nexlizet PDF File
- Nexviazyme PDF File
- Norditropin PDF File
- Norliqva PDF File
- Nortriptyline oral solution PDF File
- Nourianz PDF File
- Nucala PDF File
- Nulibry PDF File
- Nurtec PDF File
- Nutropin PDF File
- Nutropin AQ PDF File
- Nuvigil PDF File
Policies starting with O
- Ocaliva PDF File
- Ocrevus PDF File
- Octagam PDF File
- Odactra PDF File
- Ofev PDF File
- Off-label policy PDF File
- Olumiant PDF File
- Omeprazole PDF File
- Omnaris PDF File
- Omnipod PDF File
- Omnitrope PDF File
- Onexton PDF File
- Onfi PDF File
- Ongentys PDF File
- Onglyza PDF File
- Onmel PDF File
- Onpattro PDF File
- Opdivo PDF File
- Opdualag PDF File
- Opsumit PDF File
- Opzelura PDF File
- Oraceav PDF File
- Oralair PDF File
- Orencia PDF File
- Orenitram PDF File
- Oriahnn PDF File
- Orilissa PDF File
- Orkambi PDF File
- Orladeyo PDF File
- Orthovisc PDF File
- Oseni PDF File
- Osmolex ER PDF File
- Otezla PDF File
- Oxbryta PDF File
- Oxervate PDF File
- Oxlumo PDF File
- Ozobax PDF File
Policies starting with P
- Palforzia PDF File
- Palynziq PDF File
- Pantoprazole PDF File
- Panzyga PDF File
- Paroxetine Suspension PDF File
- Paxil Suspension PDF File
- Pegasys PDF File
- Pennsaid 2% solution PDF File
- Pexeva PDF File
- Picato PDF File
- Pirfenidone PDF File
- Plegridy PDF File
- Ponvory PDF File
- Pradaxa PDF File
- Praluent PDF File
- Pramipexole ER PDF File
- Pregabalin oral solution PDF File
- Prevacid Solutabs PDF File
- Prilosec Packets PDF File
- Privigen PDF File
- Procrit PDF File
- Prolastin-C PDF File
- Protonix Packets PDF File
- Provigil PDF File
- Pulmicort Flexhaler PDF File
- Purixan PDF File
- Pyrukynd PDF File
Policies starting with Q
Policies starting with R
- Rabeprazole PDF File
- Radicava PDF File
- Ragwitek PDF File
- Raloxifene PDF File
- Ramelteon PDF File
- Rapamune oral solution PDF File
- Ravicti PDF File
- Rebif PDF File
- Reblozyl PDF File
- Recorlev PDF File
- Relistor PDF File
- Releuko PDF File
- Relpax PDF File
- Relyvrio PDF File
- Remicade PDF File
- Remodulin PDF File
- Renflexis PDF File
- Repatha PDF File
- Requip XL PDF File
- Respository Corticotropin Injection PDF File
- Retin A Micro PDF File
- Retin-A PDF File
- Revatio PDF File
- Revcovi PDF File
- Rexulti PDF File
- Reyvow PDF File
- Rezurock PDF File
- Rhofade PDF File
- Riabni PDF File
- Rinvoq PDF File
- Riomet PDF File
- Riomet ER PDF File
- Risperidal oral disintegrating tablet PDF File
- Risperdal oral solution PDF File
- Risperidone oral disintegrating tablet PDF File
- Risperidone oral solution PDF File
- Ritalin LA PDF File
- Rituxan PDF File
- Rituxan Hycela PDF File
- Ropinirole ER PDF File
- Rozerem PDF File
- Ruconest PDF File
- Rufinamide PDF File
- Ruxience PDF File
- Ruzurgi PDF File
- Ryaltris PDF File
- Ryplazim PDF File
- Rytary PDF File
Policies starting with S
- Saizen PDF File
- Samsca PDF File
- Sandostatin LAR Depot PDF File
- Saphnelo PDF File
- Savaysa PDF File
- Scemblix PDF File
- Scenesse PDF File
- Secuado PDF File
- Segluromet PDF File
- Semglee PDF File
- Serostim PDF File
- Seysara PDF File
- Signifor LAR PDF File
- Sildenafil PDF File
- Silenor PDF File
- Siliq PDF File
- Simponi PDF File
- Simponi Aria PDF File
- Simvastatin oral suspension PDF File
- Sirolimus oral solution PDF File
- Skyrizi PDF File
- Skysona PDF File
- Skytrofa PDF File
- Sodium Hyaluronate PDF File
- Sofosbuvir/velpatasvir PDF File
- Sogroya PDF File
- Soliris PDF File
- Solodyn PDF File
- Soltamox PDF File
- Somatuline Depot PDF File
- Somavert PDF File
- Soolantra PDF File
- Sotyktu PDF File
- Sotylize PDF File
- Sovaldi PDF File
- Spevigo PDF File
- Spinraza PDF File
- Sporanox PDF File
- Spravato PDF File
- Steglatro PDF File
- Steglujan PDF File
- Stelara PDF File
- Stimufend PDF File
- Strensiq PDF File
- Striant PDF File
- Sumatriptan injection PDF File
- Sumatriptan/naproxen PDF File
- Sumavel Dosepro PDF File
- Sunosi PDF File
- Supartz PDF File
- Susvimo PDF File
- Symdeko PDF File
- Sympazan PDF File
- Symproic PDF File
- Synagis PDF File
- Syndros PDF File
- Synojoynt PDF File
- Synvisc PDF File
- Synvisc-One PDF File
Policies starting with T
- Tadalafil PDF File
- Tadliq PDF File
- Takhzyro PDF File
- Taltz PDF File
- Tamoxifen PDF File
- Tarpeyo PDF File
- Tascenso PDF File
- Tasmar PDF File
- Tavaborole topical PDF File
- Tavalisse PDF File
- Tavneos PDF File
- Tazarotene 0.1% foam PDF File
- Tecartus PDF File
- Tecfidera PDF File
- Tegsedi PDF File
- Tepezza PDF File
- Teriparatide PDF File
- Testim PDF File
- Testosterone Gel 1% PDF File
- Testosterone Gel Pump 1% PDF File
- Tezspire PDF File
- Tlando PDF File
- Tolcapone PDF File
- Tolsura PDF File
- Tolvaptan PDF File
- Tosymra PDF File
- Tracleer PDF File
- Tradjenta PDF File
- Trastuzumab PDF File
- Tremfya PDF File
- Treprostinil PDF File
- Tretin-X PDF File
- Tretinoin Micronized topical PDF File
- Tretinoin topical PDF File
- Treximet PDF File
- Trikafta PDF File
- Triluron PDF File
- Trintellix PDF File
- Trivisc PDF File
- Truxima PDF File
- Turalio PDF File
- Tymlos PDF File
- Tyrvaya PDF File
- Tysabri PDF File
- Tyvaso PDF File
- Tyvaso DPI PDF File
Policies starting with U
Policies starting with V
- Valtoco PDF File
- Vancocin PDF File
- Vancomycin PDF File
- Vascepa PDF File
- Veletri PDF File
- Veltin PDF File
- Ventavis PDF File
- Veramyst PDF File
- Veregen Ointment PDF File
- Verquvo PDF File
- Vesicare PDF File
- Viekira Pak PDF File
- Viibryd PDF File
- Vijoice PDF File
- Visco-3 PDF File
- Vogelxo PDF File
- Vonjo PDF File
- Vosevi PDF File
- Voxzogo PDF File
- VPRIV PDF File
- Vraylar PDF File
- Vtama PDF File
- Vyepti PDF File
- Vyleesi PDF File
- Vyndamax PDF File
- Vyndaqel PDF File
- Vyvgart PDF File
Policies starting with W
Policies starting with X
Policies starting with Y
Policies starting with Z
- Zavesca PDF File
- Zecuity PDF File
- Zelapar PDF File
- Zemaira PDF File
- Zepatier PDF File
- Zeposia PDF File
- Zerviate PDF File
- Zetonna PDF File
- Ziana PDF File
- Zilxi PDF File
- Zokinvy PDF File
- Zolgensma PDF File
- Zolmitriptan nasal spray PDF File
- Zolpidem sublingual tablet PDF File
- Zolpimist PDF File
- Zomacton PDF File
- Zomig Nasal Spray PDF File
- Zonisade PDF File
- Zorbtive PDF File
- Zoryve PDF File
- Zulresso PDF File
- Ztalmy PDF File
- Zyclara PDF File
- Zynteglo PDF File