Pharmacy Drug Preauthorization - DAKOTACARE - Sioux Falls, SD

Pharmacy Drug Preauthorization

These drugs are covered under the pharmacy benefit only.

DAKOTACARE members: Providers can initiate preauthorization requests by faxing the appropriate form and documentation to 1-605-274-3279 or send a secure email to pharmacy@DAKOTACARE.com.
DAKOTACARE Administrative Services members: Chemotherapy preauthorizations must be submitted online at www.connect.eviti.com; all other preauthorization requests should be faxed to 1-605-274-3279 with the appropriate form and clinical documentation.

NOTE: Not all plans cover these drugs nor require preauthorization. Please refer to the member’s policy (also known as the Master Contract) for information regarding coverage determination.

***This list does not guarantee coverage and is subject to change.***

  • 8-MOP
  • abiraterone
  • Actemra SQ
  • Actimmune
  • Adbry
  • Adcirca
  • Adempas
  • Adipex-P
  • Afinitor
  • Aimovig
  • Ajovy
  • Alecensa
  • Alunbrig
  • Alyq
  • ambrisentan
  • Ampyra
  • Aubagio
  • Austedo
  • Avonex
  • Ayvakit
  • Bafiertam
  • Balversa
  • Benlysta SQ
  • benzphetamine
  • Besremi
  • Betaseron
  • bexarotene
  • bosentan
  • Bosulif
  • Braftovi
  • Brukinsa
  • Bylvay
  • Bynfezia
  • Cablivi
  • Cabometyx
  • Calquence
  • Caprelsa
  • Carbaglu
  • carglumic acid
  • Cerdelga
  • Cholbam
  • Cibinqo
  • Cimzia
  • Cometriq
  • Copaxone
  • Copiktra
  • Cosentyx
  • Cotellic
  • Cyltezo
  • dalfampridine
  • Daurismo
  • deferasirox
  • deferiprone
  • Diacomit
  • dimethyl fumarate
  • Doptelet
  • Dupixent
  • Emcyt
  • Emgality
  • Enbrel
  • Enspryng
  • Epclusa
  • Epidiolex
  • Erivedge
  • Erleada
  • erlotinib
  • Esbriet
  • everolimus
  • Evrysdi
  • Exjade
  • Exkivity
  • Extavia
  • Fareston
  • Farydak
  • Fasenra Pen
  • Ferriprox
  • Fintepla
  • Firdapse
  • Forteo
  • Galafold
  • Gattex
  • Gavreto
  • Genotropin
  • Gilenya
  • Gilotrif
  • glatiramer
  • Glatopa
  • Gleevec
  • Harvoni
  • Hetlioz
  • Hexalen
  • Humatrope
  • Humira
  • Hycamtin
  • Ibrance
  • Iclusig
  • Idhifa
  • imatinib
  • Imbruvica
  • Increlex
  • Ingrezza
  • Inlyta
  • Inqovi
  • Inrebic
  • Iressa
  • Isturisa
  • Jadenu
  • Jakafi
  • Juxtapid
  • Jynarque
  • Kalydeco
  • Kesimpta
  • Keveyis
  • Kevzara
  • Kineret
  • Kisqali
  • Kisqali Femara
  • Korlym
  • Koselugo
  • Kuvan
  • lapatinib
  • ledipasvir/sofosbuvir
  • lenalidomide
  • Lenvima
  • Letairis
  • leuprolide non-depot
  • Livmarli
  • Lonsurf
  • Lorbrena
  • Lumakras
  • Lupaneta Pack
  • Lupkynis
  • Lynparza
  • Matulane
  • Mavenclad
  • Mavyret
  • Mayzent
  • Mekinist
  • Mektovi
  • miglustat
  • Mulpleta
  • Mycapssa
  • Mytesi
  • Natpara
  • Nerlynx
  • Nexavar
  • Nilandron
  • nilutamide
  • Ninlaro
  • nitisinone
  • Nityr
  • Norditropin
  • Nubeqa
  • Nucala
  • Nurtec
  • Nutropin AQ
  • octreotide (non-LAR)
  • Odomzo
  • Ofev
  • Olumiant
  • Omnitrope
  • Onureg
  • Opsumit
  • Opzelura
  • Orencia SQ
  • Orenitram
  • Orfadin
  • Orgovyx
  • Orkambi
  • Orladeyo
  • Otezla
  • Oxbryta
  • Oxervate
  • Palynziq
  • Pemazyre
  • phendimetrazine
  • Piqray
  • pirfenidone
  • Plegridy
  • Pomalyst
  • Ponvory
  • Praluent
  • Procysbi
  • Promacta
  • Pyrukynd
  • Qinlock
  • Qulipta
  • Ravicti
  • Rebif
  • Reblozyl
  • Regimex
  • Repatha
  • Retevmo
  • Revlimid
  • Reyvow
  • Rezurock
  • Rinvoq
  • Rozlytrek
  • Rubraca
  • Ruzurgi
  • Rydapt
  • Saizen
  • Samsca
  • Sandostatin (non-LAR)
  • sapropterin
  • Scemblix
  • Serostim
  • Signifor
  • Siliq
  • Simponi SQ
  • Skyrizi
  • Skytrofa
  • sofosbuvir/velpatasvir
  • Sogroya
  • Somavert
  • sorafenib
  • Sovaldi
  • Sprycel
  • Stelara
  • Stivarga
  • Strensiq
  • Sucraid
  • sunitinib
  • Sunosi
  • Sutent
  • Symdeko
  • Sympazan
  • Tabloid
  • Tabrecta
  • tadalafil 20mg
  • Tafinlar
  • Tagrisso
  • Taltz
  • Talzenna
  • Tarceva
  • Targretin
  • Tarpeyo
  • Tascenso
  • Tasigna  
  • Tavalisse
  • Tavneos
  • Tazverik
  • Tecfidera
  • Tegsedi
  • Temodar
  • temozolomide
  • Tepmetko
  • teriparatide
  • tetrabenazine
  • Tev-Tropin
  • Tezspire
  • Thalomid
  • Tibsovo
  • tolvaptan
  • toremifine
  • Tracleer
  • Tremfya
  • Trikafta
  • Truseltiq
  • Tukysa
  • Turalio
  • Tykerb
  • Tymlos
  • Tyvaso
  • Ubrelvy
  • Ukoniq
  • Uptravi
  • Venclexta
  • Ventavis
  • Verzenio
  • Vijoice
  • Vitrakvi
  • Vizimpro
  • Vonjo
  • Vosevi
  • Votrient
  • Voxzogo
  • Vtama
  • Vumerity
  • Vyndamax
  • Wakix
  • Welireg
  • Xalkori
  • Xeljanz
  • Xenazine
  • Xermelo
  • Xolair prefilled syringe
  • Xospata
  • Xpovio
  • Xtandi
  • Xuriden
  • Xyrem
  • Yonsa
  • Zavesca
  • Zejula
  • Zelboraf
  • Zepatier
  • Zeposia
  • Zokinvy
  • Zolinza
  • Zomacton
  • Zorbtive
  • Zydelig
  • Zykadia
  • Zytiga

Reviewed by LJS/KMP on 8/18/2022