Drug prior authorization forms
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General drug forms
Specific drug forms
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A
Abstral - Medicare only (59KB PDF) - Updated 06/2011
Abstral (203KB PDF) - Updated 11/2011
Aciphex (109KB PDF) - Updated 11/2011
Actemra (124KB PDF) - Updated 03/2011
Acthar (147KB PDF) - Updated 11/2011
Actimmune - Medicare only (126KB PDF) - Updated 11/2011
NEW Adcetris (50KB PDF) - Added 11/2011
Adcirca (70KB PDF) - Updated 07/2011
Amevive (199KB PDF) - Updated 09/2011
Amnesteem - Medicaid only (122KB PDF) - Updated 11/2011
Amprya - Medicare only (234KB PDF) - Updated 11/2011
Ampyra (105KB PDF) - Updated 11/2011
Anzemet - Medicare only (57KB PDF) - Updated 01/2012
Aralast (65KB PDF) - Updated 04/2011
Aranesp - Medicaid only (Use specialty order form for HMO, PPO, POS) (171KB PDF) - Updated 09/2011
Aranesp - Medicare only (Use specialty order form for HMO, PPO, POS) (122KB PDF) - Updated 12/2011
Arzerra - Medicare only (62KB PDF) - Updated 12/2011
Arzerra (51KB PDF) - Updated 12/2011
B
Banzel (101KB PDF) - Updated 05/2010
Benlysta (346KB PDF) - Updated 06/2011
Boniva IV - Medicare only (70KB PDF) - Updated 01/2012
Boniva IV (76KB PDF) - Updated 01/2012
Botox - Medicare only (176KB PDF) - Updated 11/2011
Botox (209KB PDF) - Updated 11/2011
Byetta (120KB PDF) - Updated 05/2010
C
Caprelsa (69KB PDF) - Updated 07/2011
Carbaglu (40KB PDF) - Reviewed 01/2011
Celebrex -
Medicare only (83KB PDF) - Updated 12/2011
Celebrex (86KB PDF) - Updated 12/2011
Chantix (109KB PDF) - Updated 11/2011
Cimzia (certolizumab) (136KB PDF) - Updated 03/2011
D
Daliresp (122KB PDF) - Added 09/2011
Dexilant (122KB PDF) - Updated 11/2011
Dysport (170KB PDF) - Updated 07/2011
E
Emend -
Medicare only (69KB PDF) - Updated 07/2011
Enbrel (265KB PDF) - Updated 09/2011
Enteral Formulas -
Medicare only (67KB PDF) - Updated 07/2011
Enteral Formulas (441KB PDF) - Updated 04/2010
Epogen -
Medicare only (Use specialty order form for HMO, PPO, POS) (129KB PDF) - Updated 09/2011
Erbitux (115KB PDF) - Updated 09/2011
NEW Erwinaze (69KB PDF) - Added 01/2012
NEW Eylea -
Medicare only (44KB PDF) - Added 01/2012
Eylea (57KB PDF) - Updated 01/2012
F
Fabrazyme (57KB PDF) - Updated 01/2012
Fentora (203KB PDF) - Updated 11/2011
Fentanyl (203KB PDF) - Updated 11/2011
Flolan (98KB PDF) - Updated 07/2011
Firmagon (68KB PDF) - Updated 11/2010
Forteo -
Medicare only (115KB PDF) - Updated 09/2011
Forteo (117KB PDF) - Updated 09/2011
G
Gilenya (182KB PDF) - Updated 11/2011
Glassia -
Medicare only (89KB PDF) - Updated 12/2011
Glassia (65KB PDF) - Updated 04/2011
NEW Granisetron -
Medicare only (57KB PDF) - Added 01/2012
Growth Hormone -
Medicare only (117KB PDF) Updated 12/2011
H
Hepsera (113KB PDF) - Updated 11/2011
Human Growth Hormone (273KB PDF) - Updated 09/2011
Humira -
Medicare only (142KB PDF) - Updated 12/2011
Humira (196KB PDF) - Updated 12/2011
Hyalurate (129KB PDF) - Reviewed 01/2012
I
Ilaris (162KB PDF) - Updated 11/2011
Immunosuppressive Drugs - Oral -
Medicare only (145KB PDF) - Updated 09/2011
Imuran -
Medicare only (51KB PDF) - Updated 01/2011
Incivek (112KB PDF) - Updated 07/2011
Increlex (102KB PDF) - Updated 01/2012
Infergen (60KB PDF) - Updated 01/2012
Inhalation Solutions used with a nebulizer -
Medicare only (116KB PDF) - Updated 09/2011
Intravenous Immunoglobin (IVIG) (269KB PDF) - Updated 07/2011
Iressa (118KB PDF) - Updated 11/2011
Intravenous 5-HT3 Antagonists - (74KB PDF) - Updated 09/2010
J
NEW Jakafi (117KB PDF) - Added 01/2012
Januvia (109KB PDF) - Updated 05/2010
Jevtana (193KB PDF) - Updated 11/2011
K
Kineret -
Medicare only (65KB PDF) - Updated 12/2011
Kineret (97KB PDF) - Updated 12/2011
Krystexxa (128KB PDF) - Updated 03/2011
Kytril -
Medicare only (246KB PDF) - Updated 11/2011
L
NEW Lazanda (66KB PDF) - Added 01/2012
Letairis (56KB PDF) - Updated 07/2011
Lidoderm -
Medicare only (127KB PDF) - Updated 11/2011
Lidoderm (119KB PDF) - Updated 11/2011
Lovaza (58KB PDF) - Updated 01/2012
Lucentis (57KB PDF) - Updated 01/2012
M
Macugen (57KB PDF) - Updated 01/2012
Marinol -
Medicare only (118KB PDF) - Updated 11/2011
Migraine abortive medication (75KB PDF) - Updated 11/2011
Multiple sclerosis agents -
Medicaid only (90KB PDF) - Updated 03/2011
Myobloc (170KB PDF) - Updated 07/2011
N
Neulasta -
Medicare and Medicaid only (105KB PDF) - Updated 09/2011
Neupogen -
Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (108KB PDF) - Updated 09/2011
Nexium (122KB PDF) - Updated 11/2011
Non-Covered Medication (50KB PDF) - Updated 01/2012
Nplate (174KB PDF) - Updated 07/2010
NEW Nuedexta (118KB PDF) - Added 11/2011
NEW Nulojix (66KB PDF) - Added 09/2011
Nuvigil (156KB PDF) - Updated 11/2011
O
Oforta (101KB PDF) - Updated 11/2011
Ondasetron -
Medicare only (52KB PDF) - Updated 01/2012
Onglyza (109KB PDF) - Updated 05/2010
Onsolis (203KB PDF) - Updated 11/2011
Onsolis -
Medicare only (59KB PDF) - Updated 06/2011
Orencia (85KB PDF) - Updated 01/2012
Oxycodone SR -
Medicaid only (146KB PDF) - Updated 11/2011
P
Parenteral Formulations - Medicare only (67KB PDF) - Updated 07/2011
PEG-Intron (138KB PDF) - Updated 09/2011
Procrit - Medicare only (Use specialty order form for HMO, PPO, POS) (129KB PDF) - Updated 09/2011
Prolastin - Medicare only (89KB PDF) - Updated 12/2011
Prolastin (65KB PDF) - Updated 04/2011
Prolia (76KB PDF) - Updated 01/2012
Promacta (174KB PDF) - Updated 07/2010
Proton Pump Inhibitor (PPI) (110KB PDF) - Updated 11/2011
Provenge - Medicare only (159KB PDF) - Updated 11/2011
Provenge (190KB PDF) - Updated 11/2011
Provigil (115KB PDF) - Updated 1/2011
Q
Qutenza (144KB PDF) - Updated 11/2011
R
Reclast (120KB PDF) - Updated 01/2012
Regranex -
Medicare and Medicaid only (77KB PDF) - Updated 05/2010
Relenza (70KB PDF) Updated 11/2010
Relistor -
Medicare only (65KB PDF) - Updated 12/2011
Relistor (87KB PDF) - Updated 12/2011
Remicade -
Medicare only (284KB PDF) - Updated 09/2011
Remicade (272KB PDF) - Updated 09/2011
Remodulin (86KB PDF) - Updated 01/2012
Renagel -
Medicare only (94KB PDF) - Updated 11/2011
Revatio (70KB PDF) - Updated 07/2011
Rituxin -
Medicare only (186KB PDF) - Added 09/2011
Rituxin (153KB PDF) - Updated 09/2011
S
Samsca (143KB PDF) - Updated 09/2011
Sancuso (50KB PDF) - Updated 03/2011
Selzentry (108KB PDF) - Updated 11/2011
Simponi (169KB PDF) - Updated 11/2011
Soliris (87KB PDF) - Updated 11/2011
Sotret -
Medicaid only (122KB PDF) - Updated 11/2011
Stelara (186KB PDF) - Updated 11/2011
NEW Suboxone (58KB PDF) - Added 11/2011
Supplemental Supply (79KB PDF) - Updated 01/2012
Sylatron (124KB PDF) - Updated 07/2011
Symlin (99KB PDF) - Updated 05/2010
Synagis (171KB PDF) - Updated 11/2011
T
Tamiflu (126KB PDF) - Updated 11/2011
Tarceva -
Medicare and Medicaid only (113KB PDF) - Updated 11/2011
Testim -
Medicare only (78KB PDF) - Updated 01/2012
Tracleer (51KB PDF) - Updated 07/2011
Tykerb -
Medicare only (42KB PDF) - Updated 12/2011
Tykerb (63KB PDF) - Updated 12/2011
Tysabri (75KB PDF) - Updated 03/2011
Tyvaso (120KB PDF) - Updated 01/2012
U
V
Vaccines -
Medicare only (112KB PDF) - Updated 11/2011
Vectibix (120KB PDF) - Updated 09/2011
Veletri (98KB PDF) - Updated 07/2011
Ventavis (67KB PDF) - Updated 07/2011
Vibativ (67KB PDF) - Updated 07/2011
Victoza (120KB PDF) - Updated 05/2010
Victrelis (136KB PDF) - Updated 07/2011
W
X
NEW Xalkori (46KB PDF) - Added 11/2011
Xenical -
Medicaid only (134KB PDF) - Updated 09/2011
Xeomin (170KB PDF) - Updated 07/2011
Xgeva (62KB PDF) - Updated 01/2011
Xiaflex (56KB PDF) - Updated 07/2011
Xolair -
Medicare only (140KB PDF) - Updated 09/2011
Xolair (183KB PDF) - Updated 09/2011
Xyrem (78KB PDF) - Updated 03/2011
Y
Yervoy (82KB PDF) - Updated 07/2011
Z
NEW Zelboraf (72KB PDF) - Added 11/2011
Zemaira - Medicare only (89KB PDF) - Update 12/2011
Zemaira (65KB PDF) - Updated 04/2011
Zevalin (166KB PDF) - Updated 11/2011
Zofran - Medicare only (246KB PDF) - Updated 11/2011
Zorbtive (113KB PDF) - Updated 09/2011
Zytiga - Medicare only (60KB PDF) - Updated 12/2011
Zytiga (60KB PDF) - Updated 12/2011
Zyvox - Medicare only (169KB) - Updated 12/2011
Zyvox (173KB PDF) - Updated 12/2011
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