Drug prior authorization forms

Eliminate delays

We have to call for more information on 40% of all prior authorization and medical necessity drug request forms!

• Type in the information, then print the form. (Most delays are due to unclear handwriting.)
• Enter all the information required.

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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 12/2008
Actimmune - Medicare only (68KB PDF) - Updated 12/2008
Alprazolam ER - Medicaid only (70KB PDF) - Updated 12/2008
Amevive (108KB PDF) - Updated 12/2008
Amitiza - (74KB PDF) - Updated 12/2008
Amnesteem - Medicaid only (66KB PDF) - Updated 11/2008
Androgel - Androderm (105KB PDF) - Updated 09/2007
Antiemetic Medication - Medicare only (93KB PDF) - Updated 07/2008
Antiemetic Medication - Quantity limit override of formulary (101KB PDF) - Updated 11/2007
Anti-Neoplastic Medication - Oral - Medicare only (53KB PDF) - Updated 11/2007
Aralast (180KB PDF) - Updated 09/2008
Aranesp - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (115KB PDF) - Updated 09/2008

B

Banzel (98KB PDF) - Updated 05/2009
Boniva IV (90KB PDF) - Updated 09/2008
Botox (186KB PDF) - Updated 03/2009
Butorphanol Nasal Spray - Medicaid only (49KB PDF) - Updated 11/2007
Byetta (53KB PDF) - Updated 05/2009

C

Cancidas - Medicare only (133KB PDF) - Updated 11/2007
Celebrex (116KB PDF) - Updated 07/2008
Chantix (54KB PDF) - Updated 11/2007
Concerta - Medicaid only (93KB PDF) - Updated 03/2009
Crestor (98KB PDF) - Updated 01/2008

D

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

E

Enbrel (229KB PDF) - Updated 09/2008
Enteral Formulas (33KB PDF) - Updated 07/2008
Enteral Formulas - Medicare only (54KB PDF) - Updated 07/2008
Epogen Procrit - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (169KB PDF) - Updated 09/2008
Eraxis - Medicare only (131KB PDF) - Updated 11/2007
Erbitux (83KB PDF) - Updated 03/2009

F

Fabrazyme (61KB PDF) - Updated 01/2008
Forteo (71KB PDF) - Updated 09/2008

G

H

Hepsera (51KB PDF) - Updated 11/2008
Human Growth Hormone (190KB PDF) - Updated 09/2008
Humira (266KB PDF) - Updated 05/2009
Hyalurate (121KB PDF) - Reviewed 06/2009
Hypnotics - Medicaid only (107KB PDF) - Updated 11/2008

I

Immunosuppressive Drugs - Oral - Medicare only (95KB PDF) - Updated 09/2008
Increlex (87KB PDF) - Updated 01/2008
Infergen (57KB PDF) - Updated 01/2008
Inhalation Solutions used with a nebulizer - Medicare only (130KB PDF) - Updated 09/2008
Intravenous Immunoglobin (IVIG) (118KB PDF) - Updated 11/2008
Iressa (60KB PDF) - Updated 11/2007
Intravenous 5-HT3 Antagonists - (45KB PDF) - Added 07/2009

J

Januvia (53KB PDF) - Updated 05/2009

K

Kineret (126KB PDF) - Updated 09/2008

L

Lidoderm (66KB PDF) - Updated 11/2007
Lotronex - Medicare and Medicaid only (102KB PDF) - Updated 05/2009
Lovaza (formerly Omacor) (49KB PDF) - Updated 01/2008
Lyrica (75KB PDF) - Updated 11/2007

M

Marinol - Medicare only (52KB PDF) - Updated 11/2008
Methylin - Medicaid only (79KB PDF) - Updated 11/2008
Methylphenidate - Medicaid only (82KB PDF) - Updated 03/2009
Migraine Abortive Medication (67KB PDF) - Updated 11/2007
Multiple Sclerosis Agents - Medicaid only (122KB PDF) - Updated 03/2009
Mycamine - Medicare only (66KB PDF) - Updated 11/2007
Myobloc (389KB PDF) - Updated 03/2009

N

NebuPent (84KB PDF) - Updated 11/2007
Neulasta - Medicare and Medicaid only (60KB PDF) - Updated 09/2008
Neupogen - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (69KB PDF) - Updated 09/2008
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 (186KB PDF) - Updated 09/2008
Oxycodone SR - Medicaid only (151KB PDF) - Updated 11/2007

P

Parcopa (69KB PDF) - Updated 11/2008
Parenteral Formulations - Medicare only (69KB PDF) - Updated 11/2008
Pegasys (78KB PDF) - Updated 09/2008
PEG-Intron (89KB PDF) - Updated 09/2008
Penlac Nail Lacquer (70KB PDF) - Updated 11/2007
Pentam (115KB PDF) - Updated 11/2007
Prevacid (62KB PDF) - Updated 11/2008
Procrit Epogen - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS) (169KB PDF) - Updated 09/2008
Prolastin (78KB PDF) - Updated 09/2008
Promacta (76KB PDF) - Updated 05/2009
Proton Pump Inhibitor (PPI) (80KB PDF) - Updated 07/2008
Provigil (126KB PDF) - Updated 03/2009

Q

R

Reclast (62KB PDF) - Updated 09/2008
Regranex - Medicare and Medicaid only (39KB PDF) - Updated 05/2009
Relenza (88KB PDF) - Updated 11/2008
Remicade (246KB PDF) - Updated 09/2008
Remodulin (72KB PDF) - Updated 01/2008
Renagel - Medicare only (46KB PDF) - Updated 11/2008
Restasis - Medicare only (91KB PDF) - Updated 09/2008
Revatio (55KB PDF) - Updated 11/2008
Rituxin (rituximab) - (100KB PDF) - Updated 12/2008

S

Sancuso (50KB PDF) - Updated 05/2009
Self Injectables - Medicaid only (111KB PDF) - Updated 09/2008
Selzentry (74KB PDF) - Updated 11/2008
Singulair - Medicare and Medicaid only (70KB PDF) - Updated 09/2008
Sotret - Medicaid only (77KB PDF) - Updated 11/2008
Sporanox (125KB PDF) - Updated 11/2007
Supplemental Supply (83KB PDF) - Updated 01/2009
Symlin (67KB PDF) - Updated 05/2009
Synagis (142KB PDF) - Updated 11/2007

T

Tamiflu (83KB PDF) - Updated 03/2009
Tarceva - Medicare and Medicaid only (43KB PDF) - Updated 11/2007
Testosterone Supplementation (105KB PDF) - Updated 09/2007
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 11/2007

Vectibix (84KB PDF) - Updated 03/2009
Ventavis (63KB PDF) - Updated 01/2009
Vfend - Medicare and Medicaid only (61KB PDF) - Updated 11/2007
Vigamox - Medicare and Medicaid only (42KB PDF) - Updated 11/2008
Vivactil - Medicaid only (59KB PDF) - Updated 11/2008
Vyvanse - Medicaid only (56KB PDF) - Updated 05/2007

W

X

Xenical - Medicaid only (113KB PDF) - Updated 09/2008
Xolair (127KB PDF) - Updated 09/2008
Xopenex (76KB PDF) - Updated 11/2008
Xyrem (78KB PDF) - Updated 03/2009

Y

Z

Zevalin (83KB PDF) - Updated 11/2007
Zofran - Medicare only (85KB PDF) - Updated 05/2009
Zorbtive (43KB PDF) - Updated 07/2008  
Zymar - Medicare and Medicaid only (42KB PDF) - Updated 11/2008
Zyvox (54KB PDF) - Updated 11/2008