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 - SpecialtyOlumiant (baricitinib)
Anti-inflammatory - SpecialtyOtezla (apremilast)
Anti-inflammatory - SpecialtyXeljanz and Xeljanz XR (tofacitinib)
Anti-obesity *Contrave (naltrexone, bupropion)
Anti-obesity *Saxenda (liraglutide)
Anti-obesity *Xenical (orlistat)
AntiviralPrevymis (letermovir)
AsthmaCinqair (reslizumab)
AsthmaFASENRA (benralizumab)
AsthmaNucala (mepolizumab)
AsthmaXolair (omalizumab)
Benign prostate enlargement *Avodart (dutasteride), Proscar (finasteride)
Biologic response modifierActemra (tocilizumab)
Biologic response modifierCimzia (certolizumab pegol)
Biologic response modifierCosentyx (secukinumab)
Biologic response modifierDupixent (dupilumab)
Biologic response modifierENBREL, BRENZYS, ERELZI (etanercept)
Biologic response modifierEntyvio (vedolizumab)
Biologic response modifierHumira (adalimumab)
Biologic response modifierIlaris (canakinumab)
Biologic response modifierKevzara (sarilumab)
Biologic response modifierKineret (anakinra)
Biologic response modifierOrencia (abatacept)
Biologic response modifierREMICADE, INFLECTRA, RENFLEXIS (infliximab)
Biologic response modifierRemsima (infliximab)
Biologic response modifierRituxan (rituximab)
Biologic response modifierSiliq (brodalumab)
Biologic response modifierSimponi (golimumab)
Biologic response modifierSKYRIZI (risankizumab)
Biologic response modifierStelara (ustekinumab)
Biologic response modifierTALTZ (ixekizumab)
Biologic response modifierTREMFYA (guselkumab)
Blood disorder therapyExjade (deferasirox)
Blood disorder therapyFerriprox (deferiprone)
Blood disorder therapyJadenu (deferasirox)
Blood disorder therapyNeupogen (filgrastim)
CancerAbraxane (nab-paclitaxel)
CancerAdcetris (brentuximab)
CancerAfinitor (everolimus)
CancerAlecensaro (alectinib)
CancerAlimta (pemetrexed)
CancerALUNBRIG (brigatinib)
CancerAvastin (bevacizumab)
CancerBAVENCIO (avelumab)
CancerBosulif (bosutinib)
CancerCabometyx (cabozantinib)
CancerCaprelsa (vandetanib)
CancerCotellic (cobimetinib)
CancerCyramza (trastuzumab)
CancerDarzalex (daratumumab)
CancerErbitux (cetuximab)
CancerErivedge (vismodegib)
CancerERLEADA (apalutamide)
CancerFOLOTYN (pralatrexate)
Cancer *GAZYVA (obinutuzumab)
CancerGiotrif (afatinib dimaleate)
CancerGleevec (imatinib mesylate)
CancerHERCEPTIN-OGIVRI-TRAZIMERA-HERZUMA (trastuzumab)
CancerIbrance (palbociclib)
CancerIclusig (ponatinib)
CancerIDHIFA (enasidenib)
CancerImbruvica (ibrutinib)
CancerIMFINZI (durvalumab)
CancerInlyta (axitinib)
CancerIressa (gefitinib)
CancerJakavi (ruxolitinib)
CancerJevtana (cabazitaxel)
CancerKadcyla (trastuzumab emtansine)
CancerKeytruda (pembrolizumab)
CancerKisqali (ribociclib)
CancerKYMRIAH (Tisagenlecleucel)
CancerKyprolis (carfilzomib)
CancerLARTRUVO (olaratumab)
CancerLenvima (lenvatinib)
CancerLonsurf (tipiracil, trifluridine)
CancerLORBRENA (lorlatinib)
CancerLynparza (olaparib)
CancerMatulane (procarbazine)
CancerMvasi (bevacizumab)
CancerNexavar (sorafenib)
CancerNINLARO (ixazomib)
CancerOpdivo (nivolumab)
Cancer *OXALIPLATIN (oxaliplatin)
CancerPerjeta (pertuzumab) and Perjeta-Herceptin Combo Pack (pertuzumab-trastuzumab)
CancerPomalyst (pomalidomide)
CancerRevlimid (lenalidomide)
CancerRydapt (midostaurin)
CancerSprycel (dasatinib)
CancerStivarga (regorafenib)
CancerSutent (sunitinib)
CancerTafinlar (dabrafenib) and Mekinist (trametinib)
CancerTagrisso (osimertinib)
CancerTarceva (erlotinib)
CancerTasigna (nilotinib)
CancerTecentriq (atezolizumab)
CancerTemodal (temozolomide)
CancerThalomid (thalidomide)
CancerTreanda (bendamustine)
CancerTykerb (lapatinib)
Cancer *VELCADE (bortezomib)
CancerVenclexta (venetoclax)
CancerVERZENIO (abemaciclib)
CancerVidaza (azacitidine)
CancerVITRAKVI (larotrectinib)
CancerVIZIMPRO (dacomitinib)
CancerVotrient (pazopanib)
CancerXalkori (crizotinib)
CancerXtandi (enzalutamide)
CancerYervoy (ipilimumab)
CancerYESCARTA (Axicabtagene ciloleucel)
CancerZelboraf (vemurafenib)
CancerZolinza (vorinostat)
CancerZydelig (idelalisib)
CancerZykadia (ceritinib)
CancerZytiga (abiraterone)
Cholesterol disordersJuxtapid (lomitapide)
Cholesterol disordersPRALUENT (alirocumab)
Cholesterol disordersRepatha (evolocumab)
Cystic FibrosisKALYDECO (ivacaftor)
Cystic FibrosisOrkambi (lumacaftor/ivacaftor)
Cystic FibrosisSYMDEKO (tezacaftor-ivacaftor)
DiabetesAdlyxine (lixisenatide)
DiabetesBydureon (exenatide)
DiabetesByetta (exenatide)
DiabetesOzempic (semaglutide)
DiabetesTrulicity (dulaglutide)
DiabetesVictoza (liraglutide)
Erectile dysfunction *Cialis (tadalafil), Levitra (vardenafil), Staxyn (vardenafil), Viagra (sildenafil)
Erectile dysfunction *Cialis Once-a-Day (tadalafil)
Growth HormoneGENOTROPIN, HUMATROPE, NORDITROPIN, NUTROPIN, OMNITROPE, SAIZEN (somatropin)
Heart disease therapyEntresto (sacubitril/valsartan)
HepatitisDaklinza (daclatasvir)
HepatitisEpclusa (sofosbuvir/velpatasvir)
HepatitisHarvoni (ledipasvir/sofosbuvir)
HepatitisIbavyr (ribavirin)
HepatitisMaviret ( (glecaprevir/pibrentasvir)
HepatitisPegasys (peginterferon)
HepatitisSovaldi (sofosbuvir)
HepatitisVosevi (sofosbuvir/velpatasvir/voxilaprevir)
HepatitisZepatier (elbasvir/grazoprevir)
Human immunodeficiency virus (HIV)Egrifta (tesamorelin)
Human immunodeficiency virus (HIV)SEROSTIM (somatropin)
Kidney DisordersSamsca (tolvaptan)
Migraine headacheAimovig (erenumab)
Migraine headache *Amerge (naratriptan), Axert (almotriptan), Frova (frovatriptan), Imitrex (sumatriptan), Maxalt (rizatriptan), Relpax (eletriptan), Zomig (zolmitriptan)
Migraine headache Botox (onabotulinumtoxin A)
Migraine headache EMGALITY (galcanezumab)
Multiple sclerosisAubagio (teriflunomide)
Multiple sclerosisAvonex (interferon beta-1a)
Multiple sclerosisBetaseron (interferon beta-1b)
Multiple sclerosisExtavia (interferon beta-1b)
Multiple sclerosisGilenya (fingolimod)
Multiple sclerosisGLATECT-COPAXONE (glatiramer)
Multiple sclerosisLemtrada (alemtuzumab)
Multiple sclerosisMavenclad (cladribine)
Multiple sclerosisOcrevus (ocrelizumab)
Multiple sclerosisPlegridy (peginterferon beta-1a)
Multiple sclerosisRebif (interferon beta-1a)
Multiple sclerosisTecfidera (demethyl fumarate)
Multiple sclerosisTysabri (natalizumab)
Muscle or nerve disorderBotox (onabotulinumtoxin A)
Muscle or nerve disorderDysport Therapeutic (abobotulinumtoxinA)
Muscle or nerve disorderXeomin (incobotulinumtoxinA)
OsteoporosisEVENITY (romosozumab)
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 diseasesBRINUERA (cerliponase alfa)
Rare diseasesCarbaglu (carglumic acid)
Rare diseasesCAYSTON (aztreonam)
Rare diseasesCerdelga (eliglustat)
Rare diseasesCerezyme (imiglucerase)
Rare diseasesCRESEMBA (isavuconazole)
Rare diseasesCRYSVITA (burosumab)
Rare diseasesCystadrops (cysteamine hydrochloride)
Rare diseasesDiacomit (stiripentol)
Rare diseasesElaprase (idursulfase)
Rare diseasesElelyso (taliglucerase alfa)
Rare diseasesEsbriet (pirfenidone)
Rare diseasesFirazyr (icatibant acetate)
Rare diseasesGALAFOLD (migalastat)
Rare diseasesJinarc (tolvaptan)
Rare diseasesKANUMA (sebelipase alfa)
Rare diseasesKuvan (sapropterin)
Rare diseasesMyozyme (alglucosidase alfa)
Rare diseasesNaglazyme (galsulfase)
Rare diseasesNplate (romiplostim)
Rare diseasesOCALIVA (obeticholic acid)
Rare diseasesOfev (nintedanib)
Rare diseasesONPATTRO (patisiran)
Rare diseasesOrfadin (nitisinone)
Rare diseasesOXERVATE (cenegermin)
Rare diseasesPheburane (sodium phenylbutyrane)
Rare diseasesPROCYSBI (cysteamine bitartrate)
Rare diseasesProlastin-C (alpha1-proteinase inhibitor)
Rare diseasesPulmozyme (dornase alfa)
Rare diseasesQUINSAIR (levofloxacin)
Rare diseasesRADICAVA (edaravone)
Rare diseasesRavicti (glycerol phenylbutyrate)
Rare diseasesRevestive (teduglutide)
Rare diseasesRevolade (eltrombopag)
Rare diseasesSignifor and Signifor LAR (pasireotide)
Rare diseasesSoliris (eculizumab)
Rare diseasesSomavert (pegvisomant)
Rare diseasesSPINRAZA (nusinersen)
Rare diseasesStrensiq (asfotase alfa)
Rare diseasesTEGSEDI (inotersen)
Rare diseasesVimizim (elosulfase alfa)
Rare diseasesVpriv (velaglucerase alfa)
Rare diseasesXermelo (telotristat ethyl)
Rare diseasesZavesca (miglustat)
Systemic lupus erythematosus (SLE)Benlysta (belimumab)
Ulcer/heartburn therapy *Dexilant (dexlansoprazole) and Nexium (esomeprazole)
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