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Arizona Community Plan Pharmacy Prior Authorization Forms

To simplify your experience with prior authorization and save time, please submit your prior authorization request through the following online portals:

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Electronic Prior Authorization (ePA)

Submit an ePA using CoverMyMeds

Select Electronic Prior Authorization (ePA)
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Electronic prior authorization (ePA)

Submit an ePA using SureScripts

Select Electronic prior authorization (ePA)

Otherwise, you can submit requests by completing and faxing the applicable form below. You can search for a drug specific form by entering the requested drug in the search box below. If your search does not yield a result, please use this Prior Authorization Request form.

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ADHD Products (Arizona) Prior Authorization Form - Community Plan

Last Published 02.22.2022

Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care

Adderall, Adderall XR, Adhansia XR, Adzenys ER, Adzenys XR, amphetamine, amphetamine/dextroamphetamine, amphetamine/dextroamphetamine ER, Aptensio XR, atomoxetine, Catapres, clonidine, clonidine ER, Concerta, Cotempla XR, Daytrana, Desoxyn, Dexedrine, dexmethylphenidate, dexmethylphenidate ER, dextroamphetamine, dextroamphetamine ER, Dyanavel, Evekeo, Evekeo ODT, Focalin, Focalin XR, guanfacine ER, guanfacine, Intuniv, Jornay PM, Kapvay, Metadate ER, methamphetamine, Methylin, methylphenidate, methylphenidate ER, Mydayis, Procentra, Quillichew, Quillivant, Ritalin, Ritalin LA, Strattera, Vyvanse, Zenzedi ,

Opioid Products (Arizona) Prior Authorization Form - Community Plan

Last Published 01.06.2023

Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care

"Morphine ER, Xtampza, tramadol ER, Hydromorphone ER, MS Contin, fentanyl transdermal, hydrocodone ER, Oxymorphone ER, Methadose, Methadone, Hysingla ER, Oxycontin, oxycodone CR, Nucynta ER, Conzip, Butorphanol, carisoprodol-aspirin-codeine, codeine, acetaminophen-codeine, butalbital-acetaminophen-caffeine-codeine, Fioricet-codeine, butalbital-aspirin-caffeine-codeine, morphine, hydrocodone-acetaminophen, Lortab, Xodol, hydrocodone-ibuprofen, Dilaudid, hydromorphone, oxycodone, Roxicodone, Oxaydo, oxycodone-acetaminophen, Percocet, Prolate, Nalocet, Endocet, oxycodone-aspirin, oxymorphone, pentazocine-naloxone, Ultram, Synapryn, tramadol, Ultracet, tramadol-acetaminophen, Qdolo, Nucynta, meperidine, levorphanol, acetaminophen-caffeine-dihydrocodeine, Trezix, belladonna alkaloids-opium, opium, Apadaz, benzhydrocodone-acetaminophen, Ascomp/codeine, Seglentis, Roxybond",