Drug prior authorization forms

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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 (49KB PDF) - Updated 02/2010
• Non-Covered Medication Prior Authorization Form (42KB PDF) - Updated 01/2010
• Medicare Part D Non Formulary, Tier or Quantity Limit Exception Prior Authorization Form (41KB PDF) Updated 08/2010

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
Actemra (102KB PDF) Added 03/2010
Acthar (85KB PDF) - Updated 11/2009
Actimmune - Medicare only (68KB PDF) - Updated 11/2009
Actiq (94KB PDF) - Reveiwed 11/2009
Aloxi (54KB PDF) - Updated 07/2009
Amevive (135KB PDF) - Updated 09/2009
Amitiza - (68KB PDF) - Updated 07/2009
Amnesteem - Medicaid only (66KB PDF) - Updated 11/2008
Ampyra (119KB PDF) - Updated 07/2010
Amprya - Medicare only (183KB PDF) - Added 07/2010
Antiemetic Medication - Medicare only (95KB PDF) - Updated 07/2009
Anzemet (54KB PDF) - Updated 07/2009
Aralast (278KB PDF) - Added 04/2010
Aranesp - Medicaid only (Use specialty order form for HMO, PPO, POS) (165KB PDF) - Updated 07/2010
Aranesp - Medicare only (Use specialty order form for HMO, PPO, POS) (214KB PDF) - Updated 07/2010

B

Banzel (101KB PDF) - Updated 05/2010
Boniva IV - Medicare only (175KB PDF) - Added 04/2010
Boniva IV (90KB PDF) - Updated 01/2010
Botox (172KB PDF) - Updated 02/2010
Byetta (120KB PDF) - Updated 05/2010

C

Celebrex (124KB PDF) - Updated 11/2009
Chantix (54KB PDF) - Updated 11/2009
Cimzia (certolizumab) (126KB PDF) - Added 11/2009

D

Dysport - (146KB PDF) - Updated 02/2010

E

Emend - Medicare only (101KB PDF) - Updated 07/2010
Enbrel (148KB PDF) - Updated 09/2009
Enteral Formulas (441KB PDF) - Updated 04/2010
Enteral Formulas - Medicare only (57KB PDF) - Updated 07/2009
Epogen - Medicare only (Use specialty order form for HMO, PPO, POS) (214KB PDF) - Updated 07/2010
Erbitux (67KB PDF) - Updated 09/2009

F

Fabrazyme (67KB PDF) - Updated 01/2010
Fentora (94KB PDF) - Reviewed 11/2009
Forteo (67KB PDF) - Updated 09/2009

G

H

Hepsera (adefovir) (64KB PDF) - Updated 11/2009
Human Growth Hormone (174KB PDF) - Updated 09/2009
Humira (180KB PDF) - Updated 05/2009
Hyalurate (219KB PDF) - Reviewed 01/2010  

I

Ilaris (103KB PDF) - Added 12/2009
Immunosuppressive Drugs - Oral - Medicare only (70KB PDF) - Updated 09/2009
Increlex (114KB PDF) - Updated 01/2010
Infergen (59KB PDF) - Updated 01/2010
Inhalation Solutions used with a nebulizer - Medicare only (115KB PDF) - Updated 09/2009
Intravenous Immunoglobin (IVIG) (112KB PDF) - Updated 09/2009
Iressa (60KB PDF) - Updated 11/2009
Intravenous 5-HT3 Antagonists - (54KB PDF) - Added 07/2009

J

Januvia (109KB PDF) - Updated 05/2010

K

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

L

Lidoderm - Medicare only (62KB PDF) - Added 12/2009
Lidoderm (64KB PDF) - Updated 11/2009
Lovaza (formerly Omacor) (62KB PDF) - Updated 01/2010

M

Marinol - Medicare only (40KB PDF) - Updated 11/2009  
Migraine Abortive Medication (67KB PDF) - Updated 11/2009
Multiple Sclerosis Agents - Medicaid only (122KB PDF) - Updated 03/2009  
Myobloc (156KB PDF) - Updated 02/2010

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 (112KB PDF) - Updated 07/2010 
Non-Covered Medication (42KB PDF) - Updated 01/2010
Nplate (174KB PDF) - Updated 07/2010
Nuvigil (102KB PDF) - Updated 08/2010

O

Omacor -- see Lovaza
Onglyza (109KB PDF) - Updated 05/2010
Onsolis (94KB PDF) - Reviewed 11/2009
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
Prevacid Solutabs (50KB PDF) - Updated 07/2010
Procrit - Medicare only (Use specialty order form for HMO, PPO, POS) (214KB PDF) - Updated 07/2010
Prolastin (278KB PDF) - Added 04/2010
Promacta (174KB PDF) - Updated 07/2010
Proton Pump Inhibitor (PPI) (69KB PDF) - Updated 07/2010
Provigil (172KB PDF) - Updated 07/2010

Q

R

Reclast (68KB PDF) - Updated 09/2009
Regranex - Medicare and Medicaid only (77KB PDF) - Updated 05/2010
Relenza (69KB PDF) Updated 11/2009
Remicade - Medicare only (108KB PDF) - Added 03/2010
Remicade (208KB PDF) - Updated 09/2009
Remodulin (87KB PDF) - Updated 01/2010
Renagel - Medicare only (46KB PDF) - Updated 11/2009
Restasis - Medicare only (91KB PDF) - Updated 09/2008
Revatio (57KB PDF) - Updated 01/2010
Rituxin - Medicare only (99KB PDF) - Added 03/2010
Rituxin (99KB PDF) - Updated 08/2010

S

Samsca (109KB PDF) - Added 10/2009
Sancuso (50KB PDF) - Updated 05/2009
Selzentry (74KB PDF) - Updated 11/2009
Sotret - Medicaid only (77KB PDF) - Updated 11/2009
Stelara (240KB PDF) - Added 12/2009
Supplemental Supply (51KB PDF) - Updated 01/2010
Symlin (99KB PDF) - Updated 05/2010
Synagis (115KB PDF) - Updated 11/2009

T

Tamiflu (69KB PDF) - Updated 11/2009
Tarceva - Medicare and Medicaid only (43KB PDF) - Updated 11/2009
Testim - Medicare only (66KB PDF) - Added 01/2010
Tykerb (100KB PDF) - Updated 05/2010
Tysabri  (178KB PDF) - Updated 07/2010
Tyvaso (56KB PDF) - Added 01/2010

U

V

Vaccines - Medicare only (44KB PDF) - Updated 11/2009

Vectibix (72KB PDF) - Updated 07/2009  
Victoza (120KB PDF) - Added 05/2010

W

X

Xenical - Medicaid only (83KB PDF) - Updated 09/2009
Xolair - Medicare only (75KB PDF) - Updated 09/2009
Xolair (126KB PDF) - Updated 09/2009
Xyrem (78KB PDF) - Updated 03/2009

Y

Z

Zemaira (278KB PDF) - Added 04/2010
Zevalin (106KB PDF) - Updated 11/2009
Zofran - Medicare only (85KB PDF) - Updated 05/2009
Zorbtive (43KB PDF) - Updated 07/2009
Zyvox (139KB PDF) - Updated 11/2009


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