Eliminate delaysWe have to call for more information on 40% of all prior authorization and medical necessity drug request forms!
General drug formsDispense as Written (DAW) Prior Authorization Form (40KB PDF) - Updated 05/2009Non-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 formsA B C D E F G H I J K L M N O P Q R S T U V W X Y ZAAciphex (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 BBanzel (98KB PDF) - Updated 05/2009Boniva 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 CCancidas - Medicare only (133KB PDF) - Updated 11/2007Celebrex (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 DDaytrana - Medicaid only (77KB PDF) - Updated 05/2009EEnbrel (229KB PDF) - Updated 09/2008Enteral 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 FFabrazyme (61KB PDF) - Updated 01/2008Forteo (71KB PDF) - Updated 09/2008 GHHepsera (51KB PDF) - Updated 11/2008Human 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 IImmunosuppressive Drugs - Oral - Medicare only (95KB PDF) - Updated 09/2008Increlex (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 JJanuvia (53KB PDF) - Updated 05/2009KKineret (126KB PDF) - Updated 09/2008LLidoderm (66KB PDF) - Updated 11/2007Lotronex - Medicare and Medicaid only (102KB PDF) - Updated 05/2009 Lovaza (formerly Omacor) (49KB PDF) - Updated 01/2008 Lyrica (75KB PDF) - Updated 11/2007 MMarinol - Medicare only (52KB PDF) - Updated 11/2008Methylin - 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 NNebuPent (84KB PDF) - Updated 11/2007Neulasta - 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 OOmacor -- see LovazaOrencia (186KB PDF) - Updated 09/2008 Oxycodone SR - Medicaid only (151KB PDF) - Updated 11/2007 PParcopa (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 QR
Reclast (62KB PDF) - Updated 09/2008
SSancuso (50KB PDF) - Updated 05/2009Self 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 TTamiflu (83KB PDF) - Updated 03/2009Tarceva - 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 UVVaccines - Medicare only (88KB PDF) - Updated 11/2007Vectibix (84KB PDF) - Updated 03/2009
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