Northern Illinois Physicians For Connectivity

Part D Preauthorization
Commonly used medications used in primary care
that require preauthorization, by trade name and class of drug.

Click the insurance provider in your medication row to download
a Medicare Part D Coverage Determination Request Form or see *notes below.

ACE Inhibitors Altace (ramipril) •CONVENTRY ADVANTRARX •HEALTHSPRING •PACIFICARE •WELLCARE SSRIs Effexor XR (Venlafaxine HCI) •HEALTHSPRING Proton Pump Inhibitors Protonix (Pantoprazole Sodium) Nexium, Prevacid, Aciphex •CAREMARK SILVERSCRIPT •CIGNA •JOHN DEERE •MEDCO •OSF HEALTHCARE NMDA Receptor Antagonist Namenda (memantine hydrochloride) •MEMBERHEALTH*** •OSF HEALTHCARE •SILVERSCRIPT* Immunologic Agents Enbrel •AMERICAN PROGRESSIVE •BC/BS •CAREMARK SILVERSCRIPT •CIGNA •CONVENTRY ADVANTRARX •JOHN DEERE •HEALTH ALLIANCE •HEALTHSPRING •HUMANA •MEDCO •MEMBERHEALTH •OSF HEALTHCARE •SILVERSCRIPT* •UNICARE/WELLPOINT •UNITED HEALTHCARE** •WELLCARE Cholesterol Lipitor ** Rhuematologic Specialty Chemotherapy Methotrexate •AETNA •CIGNA •HEALTH ALLIANCE •HUMANA •PACIFICARE

*Call Silverscript at 1-800-294-5979 for a determination by phone.
**On-line forms are not available.
***Solution only.