Colorado Community Plan Pharmacy Prior Authorization Forms

"Adderall XR, Adderall, Adhansia XR, Adzenys ER, Adzenys XR-ODT, amphetamine ER susp, amphetamine, amphetamine/dextroamphetamine ER, amphetamine/dextroamphetamine, Aptensio XR, atomoxetine, clonidine ER, Concerta, Cotempla XR-ODT, Daytrana, Desoxyn, Dexedrine, dexmethylphenidate ER, dexmethylphenidate, dextroamphetamine ER, dextroamphetamine soln, dextroamphetamine, Dyanavel XR, Evekeo ODT, Evekeo, Focalin XR, Focalin, guanfacine ER, Intuniv, Jornay PM, Kapvay, Metadate ER, methamphetamine, Methylin, methylphenidate cap, methylphenidate ER (CD), methylphenidate ER (LA), methylphenidate ER OSM, methylphenidate ER tab, methylphenidate soln, methylphenidate, Mydayis, Procentra, Quillichew ER, Quillivant XR, Relexxii, Ritalin LA, Ritalin, Strattera, Vyvanse, Zenzedi",

"Abilify Maintena, Abilify MyCite, Abilify tabs, aripiprazole ODT, aripiprazole oral solution, aripiprazole tablets, aripiprazole tabs, Aristada, Caplyta , chlorpromazine injection, chlorpromazine tablets, clozapine 200 mg tablet, clozapine ODT, clozapine tablets, clozapine, Clozaril 200mg tab, Clozaril, Fanapt, Fanapt, Fazaclo, fluphenazine, Geodon, haloperidol decanoate injection, haloperidol injection, haloperidol oral concentrate, haloperidol tablets, Invega Sustenna, Invega Trinza, Invega, Latuda, loxapine, molindone tablets, molindone, olanzapine ODT, olanzapine tablets, olanzapine, paliperidone ER, perphenazine, Perseris, pimozide, quetiapine ER, quetiapine, Rexulti, Risperdal Consta, Risperdal oral solution, Risperdal tabs, risperidone ODT, risperidone oral solution, risperidone solution, risperidone tablets, risperidone tabs, Saphris, Secuado, Seroquel XR, Seroquel, thioridazine, thiothixene, trifluoperazine, Versacloz suspension, Versacloz, Vraylar, ziprasidone, Zyprexa Zydis, Zyprexa",

"Xanax, alprazolam, Xanax XR, alprazolam ER, alprazolam intensol, alprazolam ODT, chlordiazepoxide, Tranxene T, chlorazepate, Valium, diazepam, Ativan, lorazepam, oxazepam ",

"Bydureon, Bydureon BCise, Byetta, Ozempic , Rybelsus, Victoza, Adlyxin, Trulicity ",

"Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier",

"fluticasone propionate/salmeterol diskus, Wixela Inhub, Advair HFA, Dulera, AirDuo, Symbicort, budesonide/formoterol, Advair Diskus, Breo Ellipta ",

"Flovent HFA, Alvesco, Asmanex Twisthaler, Flovent Diskus, Pulmicort Flexhaler, Asmanex HFA ",

"Arymo, Conzip, Dolophine, Duragesic, Embeda, Exalgo, fentanyl patch, hydrocodone ER, hydromorphone ER, Hysingla ER, Kadian, methadone, Methadose, Morphabond ER, morphine sulfate ER, MS Contin, Nucynta ER, oxycodone ER, oxymorphone ER, Oxycontin, tramadol ER, Xtampza ER, Zohydro ER, acetaminophen w/codeine, acetaminophen-caffeine-dihydrocodeine, Apadaz, Ascomp/Codeine, belladonna alkaloids & opium suppositories, benzhydrocodone-acetaminophen, butalbital-acetaminophen-caffeine w/codeine, butalbital-aspirin-caffeine w/codeine, butorphanol nasal spray, carisoprodol-aspirin-codeine, codeine sulfate, Dilaudid, Dvorah, Endocet, Fioricet/Codeine, Fiorinal/Codeine, Fortigan, hydrocodone-acetaminophen, hydrocodone-ibuprofen, hydromorphone, levorphanol, Lorcet HD, Lorcet Plus, Lorcet, Lortab, meperidine, morphine, Nalocet, Norco, Nucynta, Opana, opium tincture, Oxaydo, oxycodone, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, oxymorphone, pentazocine w/naloxone, Percocet, Primlev, Roxicodone, Synapryn, tramadol, tramadol-acetaminophen, Trezix, Tylenol w/Codeine, Ultracet, Ultram, Vicodin HP, Xodol",

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"Steglatro, Segluromet, Jardiance, Invokana, Synjardy, Synjardy XR, Invokamet, Invokamet XR, Xigduo XR, Farxiga",