Prior Authorization Forms for Pharmacy Services
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
The appropriate drug prior authorization (PA) form may be located by using the drug search function (at the top of this page) or by selecting the first letter of the drug to be requested (from the A to Z list displayed above). Once you find the requested drug, click on “PA” next to the drug name and the correct PA form(s) will be highlighted in yellow on the page below. If you already know which specific PA form you are looking for, you may select it from the following list by clicking on the link below.
Androgen Therapy
[
02/07/22
]
|
Anticoagulant and Antiplatelet
[
05/09/22
]
|
Anticonvulsant
[
05/09/22
]
|
Antidepressant
[
05/09/22
]
|
Antidiabetic Agents
[
12/20/21
]
|
Antiemetics
[
05/09/22
]
|
Antihistamine Agents
[
02/07/22
]
|
Antipsychotic
[
02/07/22
]
|
Antiretroviral Agents
[
03/21/22
]
|
Asthma/Allergy Monoclonal Antibodies
[
05/09/22
]
|
Benign Prostatic Hyperplasia (BPH) Agents
[
03/21/22
]
|
Benzodiazepines and Other Antianxiety Agents
[
02/07/22
]
|
Beta Thalassemia, Myelodysplastic Syndrome, and Sickle Cell Disease Agents
[
12/21/20
]
|
Brand-Name and Non-Preferred Generic Drug
[
04/22/19
]
|
Cerebral Stimulant and ADHD Drugs
[
03/21/22
]
|
Chimeric Antigen Receptor (CAR)-T Immunotherapies
[
05/09/22
]
|
Constipation Agents
[
11/01/21
]
|
Cystic Fibrosis Agents
[
08/09/21
]
|
Dermatological Agents (Topical Chemotherapy and Genital Wart Therapy)
[
03/21/22
]
|
Diabetes Medical Supplies and Emergency Treatments
[
11/01/21
]
|
Erythropoiesis-Stimulating Agents
[
05/09/22
]
|
Gastrointestinal Agents - Antidiarrheals and Bowel Preparation Agents
[
02/07/22
]
|
General Drug
[
07/15/19
]
|
Glaucoma Agents
[
05/09/22
]
|
Gonadotropin-Releasing Hormone
[
02/07/22
]
|
Gout Agents
[
09/20/21
]
|
Growth Hormone and Increlex
[
03/21/22
]
|
Headache Therapy (Butalbital Combination Agents)
[
03/21/22
]
|
Headache Therapy (Calcitonin Gene-Related Peptide [CGRP] Inhibitors)
[
03/21/22
]
|
Headache Therapy (Ergot Alkaloids and Serotonin Receptor Agents)
[
05/09/22
]
|
Heart Failure Agents
[
03/21/22
]
|
Hepatitis Antiviral Agents
[
02/07/22
]
|
Hereditary Angioedema Agents
[
06/28/21
]
|
Hyaluronan Injections
[
05/09/22
]
|
Hypnotic Agents
[
12/20/21
]
|
Immune Globulin
[
02/07/22
]
|
Inhaled Respiratory Agents
[
11/01/21
]
|
Injectable Antibiotic
[
05/09/22
]
|
Intranasal Corticosteroids
[
03/21/22
]
|
Lipid-Lowering Agents
[
05/09/22
]
|
Multiple Sclerosis Agents
[
06/28/21
]
|
Narcolepsy and Miscellaneous Sleep Disorder Therapy Agents
[
12/20/21
]
|
Neuromuscular Agents
[
12/20/21
]
|
Nonsteroidal Anti-Inflammatory Drugs (NSAID)
[
05/09/22
]
|
Oncology Agents
[
10/07/19
]
|
Ophthalmic Anti-Allergy and Anti-Inflammatory Agents
[
05/09/22
]
|
Opioid Dependence and Reversal Agents
[
02/07/22
]
|
Opioids/Acetaminophen Analgesic
[
09/20/21
]
|
Oral Antibiotics and Anti-Infectives
[
05/09/22
]
|
Oral Respiratory Agents
[
05/09/22
]
|
Oral/Injectable Antifungal Agents
[
02/07/22
]
|
Osteoporosis Agents and Calcium Regulators
[
05/09/22
]
|
Otic Agents
[
11/01/21
]
|
Pediatric Behavioral Health Medication Initiative
[
02/07/22
]
|
Pediculicides and Scabicides
[
03/21/22
]
|
Progesterone Agents
[
12/20/21
]
|
Prostate Cancer Agents
[
12/20/21
]
|
Proton Pump Inhibitor
[
02/07/22
]
|
Pulmonary Arterial Hypertension
[
02/07/22
]
|
Targeted Immunomodulators
[
05/09/22
]
|
Thrombocytopenic Agents
[
05/09/22
]
|
Topical Anesthetics
[
11/01/21
]
|
Topical Corticosteroids
[
11/01/21
]
|
Topical Vitamin D Analogues
[
03/22/21
]
|
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors
[
05/18/20
]
|
