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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.



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

Can't find a drug-specific form? Use the general Non-Covered Medication Prior Authorization Form

A

Acthar
Amevive
Amitiza - Medicare and Medicaid only
Androgel - Androderm
Antiemetic Medication
Anti-Neoplastic Medication - Oral - Medicare only
Aralast
Aranesp - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS)

B

Boniva
Botox
Butorphanol Nasal Spray
Byetta - Medicare and Medicaid only

C

Cancidas - Medicare only
Celebrex
Chantix
Concerta - Medicaid only
Crestor


D

Daytrana - Medicaid only
Dispense as Written (DAW)

E

Enbrel
Enteral Formulas
Enteral Formulas - Medicare only
Epogen Procrit - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS)
Eraxis - Medicare only
Erbitux

F

Fabrazyme
Forteo - Medicare and Medicaid only

G



H

Humira
Human Growth Hormone
Hyalurate

I

Immunosuppressive Drugs - Oral - Medicare only
Increlex
Inhalation Solutions used with a nebulizer - Medicare only
Intravenous 5-HT3 Antagonists (Anzemet, Kytril, and Aloxi)
Intravenous Immunoglobin (IVIG)
Iressa

J

Januvia - Medicare and Medicaid only

K

Kineret

L

Lamisil
Lidoderm
Lotronex - Medicare and Medicaid only
Lovaza (formerly Omacor)
Lupron
Lyrica


M

Methylphenidate - Medicaid only
Migraine Abortive Medication
Multiple Sclerosis
Mycamine - Medicare only
Myobloc

N

NebuPent
Neulasta and Neupogen - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS)
Non-Covered Medication

O

Omacor -- see Lovaza
Orencia
Oxycodone SR - Medicaid only

P

Pegasys - Medicare and Medicaid only
PEG-Intron
Penlac Nail Lacquer
Procrit Epogen - Medicare and Medicaid only (Use specialty order form for HMO, PPO, POS)
Prolastin
Proton Pump Inhibitor (PPI)
Provigil

Q


R

Ranexa - Medicare and Medicaid only
Raptiva
Reclast
Regranex - Medicare and Medicaid only
Relenza
Remicade
Remodulin
Restasis - Medicare and Medicaid only

S

Singulair - Medicare and Medicaid only
Sporanox
Symlin - Medicare and Medicaid only
Synagis
Supplemental Supply

 

T

Tamiflu
Tarceva - Medicare only
Tykerb
Tysabri 


U



V

Vaccines - Medicare only

Vectibix
Ventavis
Vfend - Medicare and Medicaid only
Vytorin
Vyvanse - Medicaid only


W


X

Xenical - Medicaid only
Xolair
Xyrem

Y

Z

Zevalin
Zorbtive
Zostavax - Medicare only
Zyvox

Last modified 09/17/08