Effective August 1, 2017, 6% PST is applicable to all premiums and fees for Saskatchewan divisions.

Prescription Drugs: Prior Authorization Request

 

The information below pertains to the Hour Bank and Office Supervisory Plans only.  If you are a member of the Retiree Benefit Plan, Prior Authorization forms can be found here

 

Some prescription drugs require approval before they can be covered under the Merit Contractors Association Benefit Plan. These drugs are referred to as Prior Authorization Drugs.  A list of them is provided below.  If you have been prescribed one of these medications and you wish to apply for coverage:

  1. Select the form for your medical condition under Prior Authorization Forms below.
  2. Print the form.
  3. Complete your portion of the form.
  4. Ask the prescribing physician to complete his/her section of the form.
  5. Send the completed form to Mercon Benefit Services by one of the following methods:

Email: PA@merconbenefits.com
Fax:    780.455.6068 to the attention of "Prior Auth"

Note:  it is not recommended that you send completed forms by regular mail due to potential postal service delays.

Once your request is received, it will be reviewed by an independent, clinical pharmacist as part of a transparent, evidence-based process. 

Prior Authorization Forms

Cancer                                     click here
General Request                        click here
Hepatitis C                                click here
High Cholesterol                        click here
Inflammatory Bowel Disease       click here
Multiple Sclerosis                       click here 
Psoriasis                                   click here
Rheumatoid Arthritis                  click here


Prior Authorization Drugs

Abatacept (ORENCIA)
AbobotulinumtoxinA  (DYSPORT)
Actemra  (ACTEMRA)
Adalimumab  (HUMIRA)
Adcirca  (ADCIRCA)
Adempas  (ADEMPAS)
Afatinib  (GIOTRIF)
Afinitor  (AFINITOR)
Aflibercept  (EYLEA)
Agalsidase Alfa  (REPLAGAL)
Agalsidase Beta  (FABRAZYM)
Aldurazyme  (ALDURAZ)
Alemtuzumab  (LEMTRADA)
Alertec  (ALERTEC)
Alglucosidase alfa (MYOZYME)
Alimta (ALIMTA)
Alirocumab  (PRALUENT)
Alpha-1-proteinase inhibitor  (PROLASTIN - C)
Ambrisentan  (VOLIBRIS)
Anakinra  (KINERET)
Apremilast  (OTEZLA)
Asunaprevir  (SUNVEPRA)
Aubagio  (AUBAGIO)
Avastin  (AVASTIN)      

B
Belimumab  (BENLYSTA)  
Benlysta  (BENLYSTA)
Bevacizumab  (AVASTIN)
Bosentan  (TRACLEER)  
Bosulif  (BOSULIF)  
Bosutinib  (BOSULIF)
Botox  (BOTOX)  

C
Caripul  (CARIPUL)
Cerezyme  (CEREZYME)
Ceritinib  (ZYKADIA)
Certolizumab pegol  (CIMZIA)
Cimzia  (CIMZIA)
Cosentyx  (COSENTYX) 

D
Dabrafenib Mesylate  (TAFINLAR)
Daclatasvir  (DAKLINZA)
Daklinza  (DAKLINZA)
Dasabuvir  (HOLKIRA PAK)
Dasatinab Monohydrate  (SPRYCE)
Deferasirox  (EXJADE)
Deferiprone  (FERRIPROX)
Dexamethasone  (OZURDEX)
Dimethyl fumarate  (TECF)
Duodopa  (DUODOPA)
Dysport Therapeutic (DYSPORT)  

E
Eculizumab  (SOLIRIS)
Egrifta  (EGRIFTA)
Elaprase  (ELAPRASE)
Elbasvir/Grazoprevir  (ZEPATIER)
Elelyso  (ELYSO)
Eltrombopag olamine  (REVOLADE)
Enbrel  (ENBREL)
Entyvio  (ENTYVIO)
Epclusa  (EPCULSA)
Epoprostenol  (CARIPUL / FLOLAN)
Erbitux  (ERBITUX)
Esbriet  (ESBRIET)
Etanercept  (ENBREL)
Everolimus  (AFINITOR)
Evolocumab  (REPATHA)
Exjade  (EXJADE)
Eylea  (EYLEA)  

F
Fabrazym  (FABRAZYM)
Fampridine  (Fampyra)
Fampyra   (Fampyra)
Ferriprox   (FERRIPROX)
Fingolimod Hydrochloride  (GILENYA)
Firazyr  (FIRAZYR)
Flolan  (FLOLAN)  
Fluocinolone acetonide   (RETISERT)
Forteo  (FORTEO)

G
Galexos  (GALEXOS)
Genotropin  (GENOTROP)
Gilenya  (GILENYA)
Giotrif  (GIOTRIF)
Gleevec  (GLEEVEC)
Golimumab  (SIMPONI) 

H
Harvoni  (HARVONI)
Holkira Pak  (HOLKIRA)
Humatrope  (HUMATROP)
Humira  (HUMIRA)  

I
Ibrance  (IBRANCE)
Ibrutinib  (IMBRU)
Iclusig  (PONATINIB)
Idelalisib  (ZYDELIG)
Ilaris  (ILARIS)
Imatinib mesylate  (GLEEVEC)
Imbruvica  (IMBRUVICA)
Imiglucerase  (CEREZYME)
IncobotulinumtoxinA  (XEOMIN)
Inflectra  (INFLECT)
Infliximab  (REMICADE)
Ivacaftor  (KALYDECO)
Ivacaftor/lumacaftor  (ORKAMBI)
Ixekizumab  (TALTZ) 

J
Jakavi  (JAKAVI)
Jinarc  (JINARC)
Juxtapid  (JUXTAPID) 

K
Kadcyla  (KADCYLA)
Kalydeco  (KALYDECO)
Kevzara  (KEVZARA)
Keytruda  (KEYTRUDA)
Kineret  (KINERET)
Kuvan  (KUVAN)
Kyprolis  (CARFILZOMIB) 

L
Laronidase  (ALDURAZ)
Ledipasvir  (HARVONI)
Lemtrada  (LEMTRADA)
Lenalidomide  (REVLIMID)
Liraglutide  (SAXENDA)
Lomitapide Mesylate  (JUXTAPID)
Lucentis  (LUCENTIS)
Lynparza  (LYNPARZA) 

M
Macitentan  (OPSUMIT)
Mekinist  (MEKINIST)
Mepolizumab  (NUCALA)
Miglustat  (RARE)
Modafinil  (ALERTEC)
Mozobil  (MOZOBIL)
Myobloc  (MYOBLOC)
Myozyme  (MYOZYME) 

N
Natalizumab  (TYSABRI)
Neulasta  (NEULASTA)
Nilotinib  (TASIGNA)
Norditropin Nordiflex  (NORDIT-N)
Nplate  (NPLATE)
Nucala  (NUCALA)
Nutropin  (NUTROPIN) 

O
Olaparib  (LYNPARZA)
Omalizumab  (XOLAIR)
Ombitasvir  (HOLKIRA PAK)
Ombitasvir  (TECHNIVIE)
Omnitrope  (OMNITROP)
OnabotulinumtoxinA  (BOTOX)
Opsumit  (OPSUMIT)
Orencia  (ORENCIA)
Orkambi  (ORKAMBI)
Osimertinib  (TAGRISSO)
Otezla  (OTEZLA) 
Ozurdex  (OZURDEX)

P
Palbociclib  (IBRANCE)
Paritaprevir  (HOLKIRA PAK)
Paritaprevir  (TECHNIVIE)
Pasireotide  (SIGNIFOR)
Pegfilgrastim  (NEULASTA)
Pembrolizumab  (KEYTRUDA)
Pemetrexed Disodium  (ALIMTA)
Perjeta  (PERJETA)
Pertuzumab  (PERJETA)
Pirfenidone  (ESBRIET)
Plerixafor  (MOZOBIL)
Pomalyst  (POMALYST)
Praluent  (PRALUENT)
Prolastin - C  (PROLASTIN - C) 

R
Ranibizumab  (LUCENTIS)
Regorafenib  (STIVARGA)
Remicade  (REMICADE)
Remodulin  (REMODULN)
Repatha  (REPATHA)
Replagal  (REPLAGAL)
Retisert  (RETISERT)
Revatio  (REVATIO)
Revlimid  (REVLIMID)
Revolade  (REVOLADE)
RimabotulinumtoxinB  (MYOBLOC)
Riociguat  (ADEMPAS)
Ritonavir  (HOLKIRA PAK)
Ritonavir  (TECHNIVIE)
Rituxan  (RITUXAN)
Rituximab  (RITUXAN)
Romiplastim  (NPLATE)
Ruxolitinib  (JAKAVI) 

S
Saizen   (SAIZEN)
Samsca (SAMSCA)
Sapropterin Dihydrochloride  (KUVAN)
Sarilumab  (KEVZARA)
Sativex  (SATIVEX)
Saxenda  (SAXENDA)
Secukinumab  (COSENTYX)
Serostim  (SEROSTIM)
Signifor  (SIGNIFOR)
Sildenafil citrate  (REVATIO)
Simeprevir  (GALEXOS)
Simponi  (SIMPONI)
Sodium oxybate  (XYREM)
Sofosbuvir  (EPCLUSA)
Sofosbuvir  (HARVONI)
Sofosbuvir  (SOVALDI)
Sofosbuvir/velpatasvir  (EPCULSA)
Soliris  M6453(SOLIRIS)
Somatropin (Genotropin)  (GENOTROP)
Somatropin (Humatrope)  (HUMATROP)
Somatropin (Norditropin Nordiflex)  (NORDIT-N)
Somatropin (Nutropin)  (NUTROPIN)
Somatropin (Omnitrope)  (OMNITROP)
Somatropin (Saizen)  (SAIZEN)
Somatropin (Serostim)  (SEROSTIM)
Sovaldi  (Solvadi)
Sprycel  (SPRYCE)
Stelara  (STELARA)
Stivarga  (STIVARGA)
Sunitinib Malate  (SUTENT)
Sunvepra  (SUNVEPRA)
Sutent  (SUTENT) 

T
Tadalafil  (ADCIRCA)
Tafinlar  (TAFINLAR)
Tagrisso  (OSIMERTINIB)
Taliglucerase  (ELELYSO)
Taltz  (IXEKIZUMAB)
Tasigna  (TASIGNA)
Tecfidera  (TECF)
Technivie  (TECHNIVIE)
Teriflunomide  (AUBAGIO)
Teriparatide  (FORTEO)
Tesamorelin  (EGRIFTA)
Tetranabinex/Nabidiolex-Cannabis Sativa L  (SATIVEX)
Tocilizumab  (ACTEMRA)
Tolvaptan  (JINARC)
Tolvaptan  (SAMSCA)
Tracleer  (TRACLEER)
Trametinib  (MEKINIST)
Trastuzmab emtansine  (KADCYLA)
Treprostinil sodium  (REMODULN)
Tysabri  (TYSABRI) 

U
Ustekinumab  (STELARA)

V
Vedolizumab  (ENTYVIO)
Velaglucerase alfa  (VPRIV)
Velpatasvir  (EPCLUSA)
Vemurafenib  (ZELBORAF)
Vpriv  (VPRIV) 

X
Xeljanz (XELJANZ)
Xeomin  (XEOMIN)
Xolair  (XOLAIR)
Xyrem  (XYREM) 

Y
Yervoy  (YERVOY)

Z
Zavesca  (RARE)
Zelboraf  (ZELBORAF)
Zepatier  (HEPC)
Zydelig  (ZYDELIG)
Zykadia (ZYKADIA)