Drug prior authorization forms

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General drug forms

Dispense as Written (DAW) Prior Authorization Form (40KB PDF) - Updated 05/2009
Non-Covered Medication Prior Authorization Form (508KB PDF) - Updated 01/2008
Medicare Part D Non Formulary, Tier or Quantity Limit Exception Prior Authorization Form (56KB PDF) Updated 07/2008

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

Aciphex (52KB PDF) - Updated 11/2008
Acthar (85KB PDF) - Updated 11/2009
Actimmune - Medicare only (68KB PDF) - Updated 11/2009
Aloxi (54KB PDF) - Updated 07/2009
Alprazolam ER - Medicaid only (70KB PDF) - Updated 11/2009
Amevive (112KB PDF) - Updated 09/2009
Amitiza - (68KB PDF) - Updated 07/2009
Amnesteem - Medicaid only (66KB PDF) - Updated 11/2008
Antiemetic Medication - Medicare only (95KB PDF) - Updated 07/2009
Anti-Neoplastic Medication - Oral - Medicare only (53KB PDF) - Updated 11/2007
Anzemet (54KB PDF) - Updated 07/2009
Aranesp - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (115KB PDF) - Updated 09/2009

B

Banzel (98KB PDF) - Updated 05/2009
Boniva IV (90KB PDF) - Updated 09/2008
Botox (156KB PDF) - Updated 07/2009
Byetta (45KB PDF) - Updated 07/2009

C

Celebrex (116KB PDF) - Updated 11/2009
Chantix (54KB PDF) - Updated 11/2009
Cimzia (certolizumab) (108KB PDF) - Added 11/2009
Concerta - Medicaid only (93KB PDF) - Updated 03/2009

D

Daytrana - Medicaid only (77KB PDF) - Updated 05/2009

E

Enbrel (175KB PDF) - Updated 09/2009
Enteral Formulas (33KB PDF) - Updated 07/2008
Enteral Formulas - Medicare only (57KB PDF) - Updated 07/2009
Epogen Procrit - Medicare only (Use specialty order form for HMO, PPO, POS) (108KB PDF) - Updated 09/2009
Erbitux (54KB PDF) - Updated 09/2009

F

Fabrazyme (61KB PDF) - Updated 01/2008
Forteo (58KB PDF) - Updated 09/2009

G

H

Hepsera (adefovir) (52KB PDF) - Updated 11/2009
Human Growth Hormone (174KB PDF) - Updated 09/2009
Humira (266KB PDF) - Updated 05/2009
Hyalurate (134KB PDF) - Reviewed 10/2009
Hypnotics - Medicaid only (107KB PDF) - Updated 11/2009

I

Immunosuppressive Drugs - Oral - Medicare only (70KB PDF) - Updated 09/2009
Increlex (87KB PDF) - Updated 01/2008
Infergen (57KB PDF) - Updated 01/2008
Inhalation Solutions used with a nebulizer - Medicare only (105KB PDF) - Updated 09/2009
Intravenous Immunoglobin (IVIG) (109KB PDF) - Updated 09/2009
Iressa (60KB PDF) - Updated 11/2009
Intravenous 5-HT3 Antagonists - (54KB PDF) - Added 07/2009

J

Januvia (45KB PDF) - Updated 07/2009

K

Kineret (114KB PDF) - Updated 09/2009
Kytril and Zofran - Medicare only (82KB PDF) - Updated 11/2009

L

Lidoderm (64KB PDF) - Updated 11/2009
Lovaza (formerly Omacor) (49KB PDF) - Updated 01/2008

M

Marinol - Medicare only (40KB PDF) - Updated 11/2009
Methylin - Medicaid only (79KB PDF) - Updated 11/2009
Methylphenidate - Medicaid only (82KB PDF) - Updated 03/2009
Migraine Abortive Medication (67KB PDF) - Updated 11/2009
Multiple Sclerosis Agents - Medicaid only (122KB PDF) - Updated 03/2009  
Myobloc (156KB PDF) - Updated 07/2009

N

Neulasta - Medicare and Medicaid only (61KB PDF) - Updated 09/2009
Neupogen - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (74KB PDF) - Updated 09/2009
Nexium (58KB PDF) - Updated 11/2008  
Non-Covered Medication (73KB PDF) - Updated 01/2008
Nplate (120KB PDF) - Updated 05/2009

O

Omacor -- see Lovaza
Orencia (111KB PDF) - Updated 10/2009
Oxycodone SR - Medicaid only (151KB PDF) - Updated 11/2009

P

Parenteral Formulations - Medicare only (69KB PDF) - Updated 11/2009
PEG-Intron (95KB PDF) - Updated 09/2009
Pentam (115KB PDF) - Updated 11/2009
Prevacid (62KB PDF) - Updated 11/2009
Procrit Epogen - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (169KB PDF) - Updated 09/2008
Promacta (76KB PDF) - Updated 05/2009
Proton Pump Inhibitor (PPI) (66KB PDF) - Updated 07/2009
Provigil (126KB PDF) - Updated 03/2009

Q

R

Reclast (68KB PDF) - Updated 09/2009
Regranex - Medicare and Medicaid only (39KB PDF) - Updated 05/2009
Relenza (69KB PDF) Updated 11/2009
Remicade (208KB PDF) - Updated 09/2009
Remodulin (72KB PDF) - Updated 01/2008
Renagel - Medicare only (46KB PDF) - Updated 11/2009
Restasis - Medicare only (91KB PDF) - Updated 09/2008
Revatio (55KB PDF) - Updated 11/2009
Rituxin (99KB PDF) - Updated 09/2009

S

Samsca (109KB PDF) - NEW 10/2009
Sancuso (50KB PDF) - Updated 05/2009
Selzentry (74KB PDF) - Updated 11/2009
Sotret - Medicaid only (77KB PDF) - Updated 11/2009
Supplemental Supply (83KB PDF) - Updated 01/2009
Symlin (67KB PDF) - Updated 05/2009
Synagis (100KB PDF) - Updated 11/2009

T

Tamiflu (69KB PDF) - Updated 11/2009
Tarceva - Medicare and Medicaid only (43KB PDF) - Updated 11/2009
Tofranil-PM - Medicaid only (71KB PDF) - Updated 11/2008
Tranxene-SD - Medicaid only (68KB PDF) - Updated 11/2008
Tykerb (62KB PDF) - Updated 05/2007
Tysabri  (113KB PDF) - Updated 03/2009

U

V

Vaccines - Medicare only (88KB PDF) - Updated 11/2009

Vectibix (72KB PDF) - Updated 07/2009
Ventavis (63KB PDF) - Updated 01/2009
Vivactil - Medicaid only (59KB PDF) - Updated 11/2008
Vyvanse - Medicaid only (56KB PDF) - Updated 05/2007

W

X

Xenical - Medicaid only (83KB PDF) - Updated 09/2009
Xolair (126KB PDF) - Updated 09/2009
Xyrem (78KB PDF) - Updated 03/2009

Y

Z

Zevalin (83KB PDF) - Updated 11/2009
Zofran - Medicare only (85KB PDF) - Updated 05/2009
Zorbtive (43KB PDF) - Updated 07/2009 
Zyvox (54KB PDF) - Updated 11/2009


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