Drug prior authorization request forms

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General non-Medicare forms

For patients of employer group, MyPriority® individual, and Priority Health Choice (Medicaid, Healthy Michigan Plan and MIChild) plans

General Medicare forms

Drug-specific 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

Abilify® Medicare only (01/2016)
Abstral® forms Commercial (11/2016) or Medicare (11/2016)
Acitretin® Medicaid only (01/2017)
Actemra® forms Commercial (01/2017) or Medicare (01/2017)
Acthar® forms Commercial (11/2016) or Medicare (11/2016)
Actimmune® Medicare only (11/2016)
Actiq® forms Commercial (11/2016) or Medicare (11/2016)
Adcetris® Commercial & Medicaid only (11/2016)
Adcirca® forms Commercial & Medicaid (07/2016) or Medicare (07/2016)
Adempas® forms Commercial & Medicaid (06/2016) or Medicare (01/2016)
Adlyxin® MyPriority (03/2017)
Afinitor® forms Commercial & Medicaid (07/2016) or Medicare (07/2016)
Aldurazyme® Commercial & Medicaid (05/2017)
Alecensa® forms Commercial (03/2017) or Medicare (03/2017)
Alogliptin forms MyPriority® (03/2017) or Medicaid (01/2017)
Amitriptyline Medicare only (01/2016)
Amnesteem® Commercial only (05/2017)
Ampyra® forms Commercial group & Medicaid (11/2016) MyPriority (05/2017) or Medicare (11/2016)
AndroDerm® form Medicare (04/2016)
AndroGel® form Medicare (04/2016)
Anzemet® Medicare Part B vs. Part D determination (09/2016)
Aralast NP forms Commercial & Medicaid (03/2017) or Medicare (03/2017)
Aranesp® forms Medicaid (09/2016) or Medicare Part B vs. Part D determination (09/2016)
Armodafinil forms Commercial (09/2016) or Medicare (01/2017)
Arzerra® Commercial & Medicaid only (11/2016)
Aubagio® forms MyPriority only (12/2016) or Medicare (01/2017) 
Auvi-Q® Medicare only (05/2017)
Aveed® forms Commercial (12/2016) or Medicare (04/2016)
Avonex® forms MyPriority (05/2017) or Medicaid (01/2017)
Axiron® form Medicare (01/2016)
Azathioprine Medicare Part B vs. Part D determination (11/2016)

B

Banzel® forms Commercial (09/2016) or Medicare (09/2016)
Bavencio® Commercial & Medicaid only (05/2017)
Beleodaq® forms Commercial & Medicaid (09/2016) or Medicare (09/2016)
Benlysta® Commercial & Medicaid only (03/2017)
Berinert® forms Commercial (07/2016) or Medicare (01/2017)
Betaseron® MyPriority only (12/2016)
Bethkis® forms Commercial group (11/2016) or MyPriority (05/2017)
Blincyto® forms Commercial & Medicaid (03/2017) or Medicare (03/2017)
Boniva® Commercial (01/2017)
Bosulif® forms Commercial (07/2016) or Medicare (07/2016)
Botulinum toxin for Commercial & Medicaid (07/2016) or Medicare (01/2016)
Buphenyl® Commercial only (05/2016)
Buprenorphine and naloxone Medicare only (01/2017)
Bydureon® MyPriority only (01/2017)
Byetta® MyPriority only (01/2017)

C

Cabometyx™ forms Commercial (07/2016) or Medicare (08/2016)
Caprelsa® forms Commercial (05/2016) or Medicare (07/2016)
Carbaglu® forms Commercial (11/2016) or Medicare (11/2016)
Cayston® forms Commercial group and Medicaid (09/2016) or MyPriority (05/2017)
Cerezyme® Commercial & Medicaid only (05/207)
Chantix® Commercial only (11/2016)
Cholbam™ forms Commercial (05/2016) or Medicare (08/2016)
Chorionic gonadotropin Medicare only (01/2017)
Cialis® Medicare only (01/2017)
Cimzia® forms Commercial (03/2017) or Medicare (03/2017)
Cinqair® forms Commercial (07/2016 or Medicare (07/2016)
Cinryze® Commercial only (03/2017)
Claravis® forms Commercial (05/2017) or (Medicaid (07/2016)
Cometriq™ forms Commercial (07/2016) or Medicare (07/2016)
Copaxone® Medicare only (01/2017)
Cosentyx® forms Commercial and MyPriority (03/2017) or Medicare (01/2017)
Cotellic® forms Commercial (05/2017) or Medicare (01/2017)
Crinone® Medicare only (01/2017)
Cyramza® Commercial & Medicaid only (07/2016)

D

Daklinza® forms Commercial group (09/2016) or MyPriority (05/2017) or Medicare (09/2016)
Daliresp® forms Commercial (09/2016) or Medicare (09/2016)
Dalvance® Commercial (09/2016)
Daraprim® Medicaid only (07/2016)
DAW® Commercial & Medicaid only (03/2017)
Digoxin Medicare only (01/2017)
Dronabinol forms Medicaid only (03/2017) or Medicare Part B vs. Part D determination (07/2016)
Duopa® Commercial only (03/2017)

E

Elavil Medicare only (01/2016)
Elaprase® Commercial & Medicaid only (05/2017)
Elelyso® Commercial & Medicaid only (05/2017)
Emend® Medicare Part B vs. Part D determination (07/2016)
Enbrel® forms Commercial (03/2017) or Medicaid (01/2017) or Medicare (09/2016)
Entresto® forms Commercial & Medicaid (12/2016) or Medicare (09/2016)
Entyvio® Commercial & Medicaid only (11/2016)
Epclusa® forms Commercial group (09/2016) or MyPriority (05/2017) or Medicare (06/2017)
Epogen® forms Medicaid (09/2016) or Medicare Part B vs. Part D determination (09/2016)
Erbitux® forms Commercial & Medicaid (09/2016) or Medicare (09/2016)
Erivedge® forms Commercial & Medicaid (07/2016) or Medicare (07/2016)
Erwinaze® Commercial & Medicaid only (06/2016)
Esbriet® forms Commercial (01/2017) or Medicare (01/2017)
Eszopiclone Medicare only (11/2016)
Eylea® Commercial & Medicaid only (11/2016)
Extavia® MyPriority only (12/2016)

F

Fabrazyme® Commercial & Medicaid only (01/2017)
Farxiga® forms MyPriority® (05/2017) or Medicaid (05/2017)
Farydak™ forms Commercial & Medicaid (06/2016) or Medicare (06/2016)
Fentanyl citrate lozenge forms Commercial (11/2016) or Medicare (11/2016)
Fentora® forms Commercial (11/2016) or Medicare (11/2016)
Firazyr® Commercial (07/2016) or Medicare (01/2017)
Flector Medicare only (05/2016)
Flolan® Commercial & Medicaid only (07/2016)
Forteo® forms Commercial & Medicaid (09/2016) or Medicare (01/2017)
Fortesta® form Medicare (01/2017)

G

Gattex® forms Commercial (05/2016) or Medicare (07/2016)
Gazyva® forms Commercial (11/2016) or Medicare (11/2016)
Gilenya®  Medicaid only (07/2016)
Gilotrif® forms Commercial (11/2016) or Medicare (01/2017)
Glassia® forms Commercial & Medicaid (03/2017) or Medicare (03/2017)
Glatopa™ forms MyPriority (05/2017) or Medicaid (12/2016)
Gleevec® forms Commercial (07/2016) or Medicare (07/2016)
Glyxambi® MyPriority only (05/2017)
Granisetron Medicare Part B vs. Part D determination (09/2016)
Granix® Medicaid only (01/2017)

H

Harvoni® forms Commercial (09/2016) or MyPriority (05/2017) or Medicare (01/2016)
Hetlioz® forms Commercial (11/2016) or Medicare (11/2016)
Human growth hormone forms Commercial group & Medicaid (11/2016) or MyPriority (05/2017) or Medicare (01/2017)
Humira® forms Commercial (03/2017), Medicaid (03/2017) or Medicare (03/2017)
Hydroxprogesterone Caproate form Commercial & Medicaid (12/2016)
Hysingla ER® forms Commercial (03/2017) or Medicare (03/2017)

I

Ibrance® forms Commercial (03/2017) or Medicare (03/2017)
Iclusig® forms Commercial (07/2016) or Medicare (07/2016)
Ilaris® forms Commercial & Medicaid (11/2016) or Medicare (11/2016)
Imbruvica® forms Commercial (07/2016) or Medicare (01/2017)
Imipramine Medicare only (11/2016)
Imlygic® forms Commercial & Medicaid (01/2017) or Medicare (01/2017)
Immune globulin (IVIG, SCIG) forms Commercial (03/2016), Medicaid (06/2016) or Medicare (03/2016)
Immunosuppressive drugs (oral) Medicare Part B vs. Part D determination (09/2016)
Impavido® Commercial & Medicaid only (07/2016)
Increlex® Commercial & Medicaid only (01/2017)
InflectraCommercial & Medicaid only (01/2017)
Inhalation solutions used with a nebulizer Medicare Part B vs. Part D determination (09/2016)
Inlyta® forms Commercial (07/2016) or Medicare (07/2016)
Invokamet®, Invokana® forms MyPriority® (05/2017) or Medicaid (05/2017)
Iressa® Commercial only (09/2016)
IVIG forms Commercial & Medicaid (03/2017) or Medicare (03/2017)

J

Jakafi® forms Commercial & Medicaid (07/2016) or Medicare (07/2016)
Janumet®/Janumet XR®/Januvia®/Jentadueto® forms MyPriority (03/2017) or Medicaid (02/2017)
Jardiance® MyPriority only (05/2017)
Jevtana® forms Commercial & Medicaid (11/2016) or Medicare (11/2016)
Juxtapid® forms Commercial (03/2017) or Medicare (01/2017)

K

Kadcyla forms Commercial & Medicaid (05/2016) or Medicare (06/2016)
Kalbitor® forms Commercial (07/2016) or Medicare (01/2017)
Kalydeco® forms Commercial group (09/2016) or MyPriority (05/2017) or Medicare (09/2016)
Kanuma® form Commercial & Medicaid only (03/2017)
Keveyis® form Commercial only (11/2016)
Keytruda® forms Commercial & Medicaid (03/2017) or Medicare (11/2016)
Kineret® forms Commercial (01/2017) or Medicare (09/2016)
Kisqali® forms Commercial & Medicaid (05/2017) or Medicare (06/2017)
Kitabis Pak™ forms Commercial & Medicaid (12/2016) or Medicare (11/2016)
Kombiglyze® XR MyPriority only (03/2017)
Korlym® Commercial only (06/2016)
Krystexxa® Commercial & Medicaid only (03/2017)
Kynamro® forms Commercial & Medicaid (05/2016) or Medicare (01/2017)

L

Lartruvo Commerical & Medicaid only (01/2017)
Lazanda® forms Commercial (06/2016) or Medicare (11/2016)
Lemtrada® forms Commercial (01/2017) or Medicare (01/2017)
Lenvima® forms Commercial (05/2016) or Medicare (08/2016)
Letairis® Commercial & Medicaid only(05/2016)
Lidocaine 5% patch forms Commercial (03/2017) or Medicaid (03/2017) or Medicare (11/2016)
Lonsurf
® forms Commercial (11/2016) or Medicare (01/2017)
Lovaza® Commercial & Medicaid only (05/2016)
Lucentis® Commercial & Medicaid only (01/2017)
Lynparza® forms Commercial (03/2017) or Medicare (03/2017)

M

Macugen® Commercial & Medicaid only (01/2017)
Makena® Commercial & Medicaid only (11/2016)
Marqibo® Commercial & Medicaid only (11/2016)
Matulane® forms Commercial (07/2016) or Medicare (07/2016)
Mekinist® forms Commercial (09/2016) or Medicare (01/2017)
Modafinil forms Commercial (03/2017) or Medicare (03/2016)
Myalept® forms Commercial & Medicaid (01/2017) or Medicare (01/2017)
MyorisanCommercial only (05/2017)

N

Naglazyme® Commercial & Medicaid only (05/2017)
Namzaric® Medicare only (01/2017)
Natesto® forms Commercial (01/2017) or Medicare (01/2017)
Natpara® forms Commercial (07/2016) or Medicare (07/2016)
Nebupent® Medicare only (01/2017)
Neupogen® forms Medicaid (01/2017) or Medicare (09/2016) (Use specialty order form for HMO, PPO, POS)
Nexavar® forms Commercial (06/2016) or Medicare (07/2016)
Ninlaro® Commercial only (07/2016)
Nplate® forms Commercial (06/2016) or Medicare (06/2016)
Nucala® forms Commercial & Medicaid (07/2016) or Medicare Part B (11/2016)
Nuedexta® Commercial only (11/2016)
Nulojix® forms Commercial & Medicaid (11/2016) or Medicare (11/2016)
Nuplazid™ forms Commercial (07/2016) or Medicare (08/2016)
Nuvigil® forms Commercial (11/2016) or Medicare (11/2016)

O

OcalivaCommercial only (09/2016)
OcrevusCommercial & Medicaid only (05/2017)
Octreotide Medicaid only (07/2016)
Odomzo® Commercial only (11/2016)
Ofev® forms Commercial (01/2017) or Medicare (01/2017)
Olysio® Medicare only (01/2017)
Ondansetron (generic Zofran) Medicare Part B vs. Part D determination (11/2016)
Onglyza® MyPriority only (03/2017)
Onivyde® forms Commercial & Medicaid (01/2017) or Medicare (01/2017)
Onsolis® forms Commercial (11/2016) or Medicare (11/2016)
Opdivo® forms Commercial & Medicaid (03/2017) or Medicare (09/2016)
Opsumit® forms Commercial (01/2017) or Medicare (01/2017)
Oral oncology drugs Medicaid only (09/2016)
Orencia® forms Commercial (01/2017) or Medicare (09/2016)
Orenitram® ER forms Commercial (06/2016) or Medicare (06/2016)
Orfadin® forms Commercial (07/2016) or Medicare (07/2016)
Orkambi® forms Commercial group (11/2016) or MyPriority (05/2017) or Medicare (11/2016) 
Osphena® Commercial only (05/2016)
Otezla® forms Commercial (03/2017) or Medicare (01/2017) or Medicaid (07/2017) 

P

Perjeta® Commercial & Medicaid (11/2016)
Phenobarbital Medicare only (01/2017)
PlegridyMyPriority only (12/2016)
Pomalyst forms Commercial & Medicaid (06/2016) or Medicare (06/2016)
Praluent® forms Commercial (03/2017) or Medicare (03/2017)
Procrit® forms Medicaid (09/2016) or Medicare Part B vs. Part D determination (09/2016) (Use specialty order form for HMO, PPO, POS)
Prolastin
® forms Commercial & Medicaid (03/2017) or Medicare (03/2017)
Prolia® forms Commercial & Medicaid (05/2016) or Medicare (05/2016)
Promacta® forms Commercial (05/2016) or Medicare (01/2017)
Promethazine Medicare only (01/2017)
Provenge® forms Commercial & Medicaid (11/2016) or Medicare (11/2016)
Pulmozyme® forms Commercial group (11/2016) or MyPriority (05/2017) or Medicaid (03/2017)

Q, R

Ravicti® forms Commercial (06/2016) or Medicare (01/2017)
Ranexa® Medicaid only (07/2017)
Rebif® MyPriority only (12/2016)
Relistor® injection forms Commercial (12/2016) or Medicare (11/2016)
Relistor® tablets Commercial only (12/2016)
Remicade® forms Commercial (01/2017) or Medicaid (01/2017) or Medicare (09/2016)
Remodulin® Commercial only (01/2017)
Repatha® forms Commercial (03/2017) or Medicare (05/2016)
Revlimid® forms Commercial (03/2017) or Medicare (07/2016)
Rituxan® forms Commercial & Medicaid (09/2016) or Medicare (09/2016)
Rubraca® forms Commercial (03/2017) or Medicare (03/2017)
Ruconest® forms Commercial & Medicaid (01/2017) or Medicare (01/2017)

S

Sabril® Commercial only (11/2016)
Samsca
® forms Commercial (09/2016) or Medicare (09/2016)
Sancuso® Medicare only (06/2016)
Sandostatin® Medicaid only (07/2016)
Seroquel XRMedicare only (01/2017)
Serostim® forms Commercial (06/2016) or Medicare (06/2016)
Signifor® forms Commercial (07/2016) or Medicare (07/2016)
Signifor LAR® Commercial only (07/2016)
Sildenafil 20 mg tablet forms Commercial & Medicaid (10/2016) or Medicare (07/2016)
Simponi® and Simponi Aria® forms Commercial (03/2017) or Medicare (03/2017)
Sivextro® forms Commercial (03/2017) or Medicare (03/2017)
Soliqua MyPriority only (03/2017)
Soliris® forms Commercial & Medicaid (03/2017) or Medicare (03/2017)
Sovaldi® forms Commercial group (09/2016) or MyPriority (05/2017) or Medicare (01/2016)
SpinrazaCommercial only (03/2017)
Sprycel® forms Commercial (07/2016) or Medicare (07/2016)
Stelara® forms Commercial (03/2017) or Medicare (03/2017)
Stivarga® forms Commercial (07/2016) or Medicare (07/2016)
Strensiq® Commercial only (01/2017)
Striant® forms Commercial (01/2017) or Medicare (01/2017)
Suboxone® forms MyPriority (03/2017) or Medicare (01/2017)
Subsys® forms Commercial (11/2016) or Medicare (11/2016)
Supprelin LA® Commercial & Medicaid only (09/2016)
Surmontil® Medicare only (01/2017)
Sutent® forms Commercial (07/2016) or Medicare (07/2016)
Sylatron® forms Commercial (07/2016) or Medicare (07/2016)
Sylvant® forms Commercial & Medicaid (09/2016) or Medicare (09/2016)
Synagis® Commercial & Medicaid only (09/2016)
Synjardy/XR® MyPriority only (05/2017)
Synribo® Medicare only (01/2017)
Syprine® Commercial only (03/2017)

T

Taflinar® forms Commercial (09/2016) or Medicare (01/2017)
Tagrisso® Commercial only (01/2017)
Taltz® forms Commercial (03/2017) or Medicare (01/2017)
Tanzeum® forms MyPriority (01/2017) or Medicaid (01/2017)
Tarceva® forms Commercial (11/2016) or Medicare (07/2016)
Targretin® forms Commercial (07/2016) or Medicare (07/2016)
Tasigna® forms Commercial (07/2016) or Medicare (07/2016)
TecentriqCommercial & Medicaid only (09/2016)
Tecfidera® forms MyPriority (12/2016) or Medicaid Medicaid only (03/2017)
Technivie® forms Commercial group (09/2016) or MyPriority (05/2017) or Medicare (11/2016)
Temozolomide Commercial & Medicaid only (09/2016)
Testim® form Medicare (05/2014)
Testopel® Commercial only (12/2016)
Testosterone gel® forms Commercial (04/2017) or Medicare (01/2017)
Thalomid® forms Commercial (03/2017) or Medicare (07/2016)
TOBI® Podhaler™ forms Commercial group & Medicaid (11/2016) or MyPriority (05/2017)
Tobramycin Commercial & Medicaid only (12/2016)
TofranilMedicare only (11/2016)
Torisel® Medicare only (11/2016)
Tracleer® Commercial & Medicaid only (07/2016)
Tradjenta® forms MyPriority (03/2017) or Medicaid (02/2017)
Tretinoin forms Commercial (07/2016) or Medicare (07/2016)
Trulicity® MyPriority only (01/2017)
Tykerb® forms Commercial (07/2016) or Medicare (07/2016)
Tysabri® forms Commercial & Medicaid (03/2017) or Medicare (03/2017)
Tyvaso® forms Commercial (01/2017) or Medicare (01/2017)

U

Unituxin® Commercial & Medicaid only (07/2016)
Uptravi® Commercial only (03/2017)

V

Vaccines: EngerixB, Imovax rabies, Rabavert, Recombivax Medicare Part B vs. Part D determination (11/2016)
Valchlor® forms Commercial (01/2017) or Medicare (01/2017)
Vascepa® forms Commercial (01/2017) or Medicare (01/2017)
Vectibix® forms Commercial & Medicaid (09/2016) or Medicare (09/2016)
Velcade® Commercial & Medicaid (03/2017)
Veletri® Commercial & Medicaid only (07/2016)
VenclextaCommercial (07/2016 or Medicare (01/2017)
Ventavis® forms Commercial (03/2017) or Medicare (07/2016)
Vesanoid® forms Commercial (06/2016) or Medicare (07/2016)
Victoza® forms MyPriority (01/2017) or ;Medicaid (01/2017)
Viekira Pak® forms Commercial group (09/2016) or MyPriority (05/2017) or Medicare (01/2016)
Vimizim® Commercial only (06/2016)
Vivlodex® Commercial only (03/2017)
Votrient® forms Commercial (06/2016) or Medicare (07/2016)
Vpriv® Commercial & Medicaid only (05/2017)

W, X

Xalkori® forms Commercial (03/2017) or Medicare (07/2016)
Xarelto® Medicaid only (07/2016)
Xeljanz® or Xeljanz® XR forms Commercial (03/2017) or Medicare (06/2016)
XermeloCommercial only (05/2017)
Xgeva® Commercial & Medicaid only (03/2017)
Xiaflex® Commercial & Medicaid only (01/2017)
Xifaxan® Medicare only (01/2017)
Xigduo XR® MyPriority only (05/2017)
Xolair® forms Commercial & Medicaid (09/2016) or Medicare (01/2017)
Xtandi® forms Commercial & Medicaid (09/2016) or Medicare (09/2016)
Xyrem® forms Commercial (03/2017) or Medicare (03/2017)

Y

Yervoy® forms Commercial & Medicaid (01/2017) or Medicare (07/2016)
Yondelis
® forms Commercial & Medicaid (01/2017) or Medicare (01/2017)

Z

Zaleplon Quantity limit exception form Medicare only (11/2016)
Zarxio® Medicaid only (01/2017)
Zelboraf® forms Commercial (07/2016) or Medicare (07/2016)
Zemaira® forms Commercial & Medicaid (03/2017) or Medicare (03/2017)
Zenatane™ Commercial only (05/2017)
Zepatier™ forms Commercial group (09/2016) or MyPriority (05/2017) or Medicare (07/2016)
Zevalin® form Commercial & Medicaid only (11/2016)
ZinbrytaMyPriority only (12/2016)
Zohydro ER® forms Commercial (07/2016) or Medicare (05/2016); in addition, have the patient complete a Pain management agreement
Zolinza® forms Commercial & Medicaid (07/2016) or Medicare (07/2016)
Zolpidem/Zolpidem ER Quantity limit exception form Medicare only (11/2016)
Zorbtive® form Commercial only (09/2016)
Zubsolv® forms MyPriority (03/2017) or Medicare (01/2017)
Zydelig® forms Commercial (09/2016) or Medicare (09/2016)
Zykadia® forms Commercial (11/2016) or Medicare (11/2016)
Zytiga® forms Commercial & Medicaid (09/2016) or Medicare (01/2017)
Zyvox® forms Commercial & Medicaid (11/2016) or Medicare (11/2016)

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Last modified: 7/14/2017
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