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 (80KB PDF) - Updated 05/2012
Abstral (203KB PDF) - Updated 11/2011
Aciphex (109KB PDF) - Updated 11/2011
Actemra (86KB PDF) - Updated 03/2012
Acthar (154KB PDF) - Updated 05/2012
Actimmune - Medicare only (80KB PDF) - Updated 05/2012
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 (72KB PDF) - Updated 05/2012
Ampyra (105KB PDF) - Updated 11/2011
Anzemet - Medicare only (57KB PDF) - Updated 01/2012
Aralast (82KB PDF) - Updated 03/2012
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 (61KB PDF) - Updated 05/2012
Arzerra (51KB PDF) - Updated 12/2011
Avonex - Medicaid only (168KB PDF) - Updated 03/2012
B
Banzel (92KB PDF) - Updated 05/2012
Benlysta (346KB PDF) - Updated 06/2011
Betaseron - Medicaid only (168KB PDF) - Updated 03/2012
Boniva IV - Medicare only (70KB PDF) - Updated 01/2012
Boniva IV (76KB PDF) - Updated 01/2012
Botox - Medicare only (196KB PDF) - Updated 03/2012
Botox (209KB PDF) - Updated 03/2012
Bydureon (68KB PDF) - Updated 03/2012
Byetta (68KB PDF) - Updated 03/2012
C
Caprelsa (86KB PDF) - Updated 05/2012
Carbaglu (52KB PDF) - Updated 05/2012
Celebrex -
Medicare only (101KB PDF) - Updated 05/2012
Celebrex (86KB PDF) - Updated 12/2011
Chantix (109KB PDF) - Updated 11/2011
Cimzia -
Medicare only (78KB PDF) - Updated 05/2012
Cimzia (86KB PDF) - Updated 03/2012
D
Daliresp (83KB PDF) - Updated 05/2012
Dexilant (122KB PDF) - Updated 11/2011
Dysport -
Medicare only (196KB PDF) - Updated 03/2012
Dysport (209KB PDF) - Updated 03/2012
E
Emend -
Medicare only (69KB PDF) - Updated 07/2011
Enbrel (236KB PDF) - Updated 05/2012
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
Erivedge (82KB PDF) - Updated 04/2012
Eylea -
Medicare only (40KB PDF) - Updated 04/2012
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 (67KB PDF) - Updated 05/2012
Forteo (117KB PDF) - Updated 09/2011
G
Gilenya (182KB PDF) - Updated 11/2011
Glassia -
Medicare only (89KB PDF) - Updated 05/2012
Glassia (82KB PDF) - Updated 03/2012
NEW Granisetron -
Medicare only (57KB PDF) - Added 01/2012
Growth Hormone -
Medicare only (133KB PDF) Updated 05/2012
H
Hepsera (113KB PDF) - Updated 11/2011
Human Growth Hormone (273KB PDF) - Updated 09/2011
Humira -
Medicare only (142KB PDF) - Updated 05/2012
Humira (92KB PDF) - Updated 05/2012
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 -
Medicare only (110KB PDF) - Updated 05/2012
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) (252KB PDF) - Updated 05/2012
Iressa (118KB PDF) - Updated 11/2011
Intravenous 5-HT3 Antagonists - (74KB PDF) - Updated 09/2010
J
Jakafi - Medicare only (96KB PDF) - Updated 05/2012
Jakafi (71KB PDF) - Updated 04/2012
Januvia (109KB PDF) - Updated 05/2010
Jevtana (177KB PDF) - Updated 05/2012
K
Kineret -
Medicare only (64KB PDF) - Updated 05/2012
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 05/2012
Lidoderm (133KB PDF) - Updated 11/2011
Lovaza (62KB PDF) - Updated 05/2012
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 (59KB PDF) - Updated 03/2012
Myobloc -
Medicare only (196KB PDF) - Updated 03/2012
Myobloc (209KB PDF) - Updated 03/2012
N
Neulasta -
Medicare and Medicaid only (105KB PDF) - Updated 09/2011
Neupogen -
Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (109KB PDF) - Updated 05/2012
Nexium (122KB PDF) - Updated 11/2011
Non-Covered Medication (50KB PDF) - Updated 01/2012
Nplate (184KB PDF) - Updated 05/2012
Nuedexta (118KB PDF) - Added 11/2011
Nulojix (48KB PDF) - Updated 04/2012
Nulojix -
Medicare only (72KB PDF) - Updated 05/2012
Nuvigil (102KB PDF) - Updated 05/2012
O
Oforta (101KB PDF) - Updated 11/2011
Ondasetron -
Medicare only (63KB PDF) - Updated 05/2012
Onglyza (109KB PDF) - Updated 05/2010
Onsolis (203KB PDF) - Updated 11/2011
Onsolis -
Medicare only (80KB PDF) - Updated 05/2012
Orencia (77KB PDF) - Updated 01/2012
NEW Oxecta (53KB PDF) - Added 03/2012
Oxycodone SR -
Medicaid only (146KB PDF) - Updated 11/2011
P
Parenteral Formulations - Medicare only (67KB PDF) - Updated 07/2011
PEG-Intron (117KB PDF) - Updated 05/2012
Procrit - Medicare only (Use specialty order form for HMO, PPO, POS) (129KB PDF) - Updated 09/2011
Prolastin - Medicare only (89KB PDF) - Updated 05/2012
Prolastin (82KB PDF) - Updated 03/2012
Prolia - Medicare only (63KB PDF) - Updated 05/2012
Prolia (76KB PDF) - Updated 01/2012
Promacta (184KB PDF) - Updated 05/2012
Proton Pump Inhibitor (PPI) (110KB PDF) - Updated 11/2011
Provenge - Medicare only (159KB PDF) - Updated 11/2011
Provenge (190KB PDF) - Updated 11/2011
Provigil (104KB PDF) - Updated 05/2012
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 (79KB PDF) - Updated 05/2012
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 (154KB PDF) - Updated 05/2012
Sancuso (68KB PDF) - Updated 05/2012
Selzentry (108KB PDF) - Updated 11/2011
Simponi (101KB PDF) - Updated 05/2012
Soliris (102KB PDF) - Updated 05/2012
Sotret -
Medicaid only (122KB PDF) - Updated 11/2011
Stelara (186KB PDF) - Updated 11/2011
Suboxone (58KB PDF) - Added 11/2011
Supplemental Supply (79KB PDF) - Updated 01/2012
Sylatron (102KB PDF) - Updated 05/2012
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 (64KB PDF) - Updated 05/2012
Tracleer (51KB PDF) - Updated 07/2011
Tykerb -
Medicare only (58KB PDF) - Updated 05/2012
Tykerb (63KB PDF) - Updated 12/2011
Tysabri (91KB PDF) - Updated 03/2012
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 (68KB PDF) - Updated 03/2012
Victrelis (136KB PDF) - Updated 07/2011
W
X
Xalkori (66KB PDF) - Updated 05/2012
Xenical -
Medicaid only (134KB PDF) - Updated 09/2011
Xeomin -
Medicare only (196KB PDF) - Updated 03/2012
Xeomin (209KB PDF) - Updated 03/2012
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 (68KB PDF) - Updated 05/2012
Y
Yervoy (80KB PDF) - Updated 05/2012
Z
Zelboraf (78KB PDF) - Added 05/2012
Zemaira - Medicare only (89KB PDF) - Update 05/2012
Zemaira (82KB PDF) - Updated 03/2012
Zevalin (166KB PDF) - Updated 11/2011
Zofran - Medicare only (246KB PDF) - Updated 11/2011
Zorbtive (113KB PDF) - Updated 09/2011
Zytiga - Medicare only (71KB PDF) - Updated 05/2012
Zytiga (60KB PDF) - Updated 12/2011
Zyvox - Medicare only (177KB) - Updated 05/2012
Zyvox (173KB PDF) - Updated 12/2011
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