Prior Authorization Drug List and Forms

Prior Authorization Form

Here's a complete list of the Prior Authorization (PA) drug categories, drugs and forms for Pay-Direct-Drug (PDD) plan sponsors who participate in the PA program. Please note: drugs are listed by brand name but the program also applies to the generic form of the drug (lowest cost equivalent).

* Categories marked with an asterisk (*) are part of our previous PA program and are not applicable under Sun Life's enhanced prior authorization program.

For prior authorization details specific to your plan, please click here. You will need to input your group contract number.

If you're interested in finding out more about our Drug Intervention Programs, or if you're already participating in this program and have questions, please contact your Sun Life Financial Group Benefits representative.

View, download or print any of the PA forms below - just click on the form(s) you need. The forms are in Adobe Acrobat PDF format. If you don't already have Adobe Acrobat Reader, you can download it here:

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Drug CategoryDrugsPrior Authorization Form
Anti-depressant *Wellbutrin (bupropion)
Anti-inflammatory *Celebrex (celecoxib)
Anti-inflammatory - SpecialtyOtezla (apremilast)
Anti-inflammatory - SpecialtyXeljanz (tofacitinib)
Anti-obesity *Sanorex (maxindol)
Anti-obesity *Saxenda (liraglutide)
Anti-obesity *Xenical (orlistat)
AsthmaNucala (mepolizumab)
AsthmaXolair (omalizumab)
Benign prostate enlargement *Avodart (dutasteride)
Proscar (finasteride)
Biologic response modifierActemra (tocilizumab)
Biologic response modifierAmevive (alefacept)
Biologic response modifierCimzia (certolizumab pegol)
Biologic response modifierCosentyx (secukinumab)
Biologic response modifierEnbrel (etanercept)
Biologic response modifierEntyvio (vedolizumab)
Biologic response modifierHumira (adalimumab)
Biologic response modifierIlaris (canakinumab)
Biologic response modifierInflectra (infliximab)
Biologic response modifierKineret (anakinra)
Biologic response modifierOrencia (abatacept)
Biologic response modifierRemicade (infliximab)
Biologic response modifierRemsima (infliximab)
Biologic response modifierRituxan (rituximab)
Biologic response modifierSimponi (golimumab)
Biologic response modifierStelara (ustekinumab)
Blood disorder therapyExjade (deferasirox)
Blood disorder therapyFerriprox (deferiprone)
Blood disorder therapyJadenu (deferasirox)
CancerAbraxane (nab-paclitaxel)
CancerAdcetris (brentuximab)
CancerAfinitor (everolimus)
CancerAlimta (pemetrexed)
CancerAvastin (bevacizumab)
CancerBosulif (bosutinib)
CancerCaprelsa (vandetanib)
CancerCotellic (cobimetinib)
CancerCyramza (trastuzumab)
CancerErbitux (cetuximab)
CancerErivedge (vismodegib)
CancerGiotrif (afatinib dimaleate)
CancerGleevec (imatinib mesylate)
CancerHercerptin (trastuzumab)
CancerIbrance (palbociclib)
CancerIclusig (ponatinib)
CancerImbruvica (ibrutinib)
CancerInlyta (axitinib)
CancerIressa (gefitinib)
CancerJakavi (ruxolitinib)
CancerJevtana (cabazitaxel)
CancerKadcyla (trastuzumab emtansine)
CancerKeytruda (pembrolizumab)
CancerKyprolis (carfilzomib)
CancerLenvima (lenvatinib)
CancerLynparza (olaparib)
CancerMatulane (procarbazine)
CancerMekinist (trametinib)
CancerNexavar (sorafenib)
CancerOpdivo (nivolumab)
CancerPerjeta (pertuzumab) and Perjeta-Herceptin Combo Pack (pertuzumab-trastuzumab)
CancerPomalyst (pomalidomide)
CancerRevlimid (lenalidomide)
CancerRituxan (rituximab)
CancerSprycel (dasatinib)
CancerStivarga (regorafenib)
CancerSutent (sunitinib)
CancerTafinlar (dabrafenib mesylate)
CancerTarceva (erlotinib)
CancerTasigna (nilotinib)
CancerTemodal (temozolomide)
CancerThalomid (thalidomide)
CancerTreanda (bendamustine)
CancerTykerb (lapatinib)
CancerVidaza (azacitidine)
CancerVotrient (pazopanib)
CancerXalkori (crizotinib)
CancerXtandi (enzalutamide)
CancerYervoy (ipilimumab)
CancerZelboraf (vemurafenib)
CancerZolinza (vorinostat)
CancerZydelig (idelalisib)
CancerZykadia (ceritinib)
CancerZytiga (abiraterone)
Cholesterol disordersPraluent (alirocumab)
Cholesterol disordersRepatha (evolocumab)
DiabetesBydureon (exenatide)
DiabetesByetta (exenatide)
DiabetesEperzan (albiglutide)
DiabetesTrulicity (dulaglutide)
DiabetesVictoza (liraglutide)
Erectile dysfunction *Cialis (tadalafil)
Levitra (vardenafil)
Staxyn (vardenafil)
Viagra (sildenafil)
Erectile dysfunction *Cialis (tadalafil) Once-a-Day
Heart disease therapyEntresto (sacubitril/valsartan)
HepatitisDaklinza (daclatasvir)
HepatitisGalexos (simeprevir)
HepatitisHarvoni (ledipasvir/sofosbuvir)
HepatitisHolkira Pak (ombitasvir/paritaprevir/ritonavir and dasabuvir tablets)
HepatitisIbavyr (ribavirin)
HepatitisPegasys (peginterferon)
HepatitisPegasys RBV (peginterferon/ribavirin)
HepatitisPegetron (peginterferon/ribavirin)
HepatitisSovaldi (sofosbuvir)
HepatitisSunvepra (asunaprevir)
HepatitisTechnivie (ombitasvir/paritaprevir/ritonavir)
HepatitisVictrelis (boceprevir)
Victrelis Triple (boceprevir/peginterferon/ribavirin)
HepatitisZepatier (elbasvir/grazoprevir)
Human immunodeficiency virus (HIV)Egrifta (tesamorelin)
Kidney DisordersSamsca (tolvaptan)
Migraine headache *Amerge (naratriptan)
Axert (almotriptan)
Frova (frovatriptan)
Imitrex (sumatriptan)
Maxalt (rizatriptan)
Relpax (eletriptan)
Zomig (zolmitriptan)
Migraine headache *Botox (onabotulinumtoxinA)
Multiple sclerosisAubagio (teriflunomide)
Multiple sclerosisAvonex (interferon beta-1a)
Multiple sclerosisBetaseron (interferon beta-1b)
Multiple sclerosisCopaxone (glatiramer acetate)
Multiple sclerosisExtavia (interferon beta-1b)
Multiple sclerosisGilenya (fingolimod)
Multiple sclerosisLemtrada (alemtuzumab)
Multiple sclerosisPlegridy (peginterferon beta-1a)
Multiple sclerosisRebif (interferon beta-1a)
Multiple sclerosisTecfidera (demethyl fumarate)
Multiple sclerosisTysabri (natalizumab)
Muscle or nerve disorderBotox (onabotulinumtoxinA)
Muscle or nerve disorderXeomin (incobotulinumtoxinA)
OsteoporosisForteo (teriparatide)
Pulmonary hypertensionAdcirca (tadalafil)
Pulmonary hypertensionAdempas (riociguat)
Pulmonary hypertensionCaripul (epoprostenol sodium)
Pulmonary hypertensionFlolan (epoprostenol sodium)
Pulmonary hypertensionOpsumit (macitentan)
Pulmonary hypertensionRemodulin (treprostinil sodium)
Pulmonary hypertensionRevatio (sildenafil)
Pulmonary hypertensionTracleer (bosentan monohydrate)
Pulmonary hypertensionUptravi (selexipag)
Pulmonary hypertensionVolibris (ambrisentan)
Rare diseasesCarbaglu (carglumic acid)
Rare diseasesCerezyme (imiglucerase)
Rare diseasesDiacomit (stiripentol)
Rare diseasesElaprase (idursulfase)
Rare diseasesElelyso (taliglucerase alfa)
Rare diseasesEsbriet (pirfenidone)
Rare diseasesFirazyr (icatibant acetate)
Rare diseasesJinarc (tolvaptan)
Rare diseasesJuxtapid (lomitapide)
Rare diseasesKalydeco (ivacaftor)
Rare diseasesKuvan (sapropterin)
Rare diseasesMyozyme (alglucosidase alfa)
Rare diseasesNaglazyme (galsulfase)
Rare diseasesNplate (romiplostim)
Rare diseasesOfev (nintedanib)
Rare diseasesOrkambi (lumacaftor/ivacaftor)
Rare diseasesPheburane (sodium phenylbutyrane)
Rare diseasesProlastin-C (alpha1-proteinase inhibitor)
Rare diseasesPulmozyme (dornase alfa)
Rare diseasesRavicti (glycerol phenylbutyrate)
Rare diseasesRevestive (teduglutide)
Rare diseasesRevolade (eltrombopag)
Rare diseasesSignifor (pasireotide)
Rare diseasesSoliris (eculizumab)
Rare diseasesSomavert (pegvisomant)
Rare diseasesStrensiq (asfotase alfa)
Rare diseasesVimizim (elosulfase alfa)
Rare diseasesVpriv (velaglucerase alfa)
Rare diseasesZavesca (miglustat)
Systemic lupus erythematosus (SLE)Benlysta (belimumab)
Ulcer/heartburn *Dexilant (dexlansoprazole)
Nexium (esomeprazole)