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Antiviral Monoclonal Antibodies (Indiana) Prior Authorization Form - Community Plan
Last Published 09.30.2024
Synagis,
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Benzodiazepine and Opioid Concurrent Therapy (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
"Belbuca, fentanyl patch, Hysingla ER, hydrocodone ER, Oxymorphone ER, Xtampza ER, Qdolo, tramadol, Conzip, tramadol ER, Butrans, buprenorphine patch, MS Contin, morphine ER, morphine CR, Nucynta ER, Oxycontin, Oxycodone ER, hydromorphone ER, methadone, methadose, butorphanol, acetaminophen/codeine, Fioricet/codeine, butalbital/acetaminophen/caffeine/codeine, ascomp/codeine, butalbital/aspirin/caffeine/codeine, Apadaz, Benzhydrocodone/acetaminophen, morphine, codeine, Lortab, hydrocodone/acetaminophen, Xodol, hydrocodone/ibuprofen, Trezix, acetaminophen/caffeine/dihydrocodeine, dilaudid, hydromorphone, oxycodone, Roxicodone, Percocet, Nalocet, Endocet, Prolate, Oxycodone/acetaminophen, oxycodone/aspirin, levorphanol, meperidine, Fortigan, oxymorphone, pentazocine/naloxone, Ultram, tramadol, Ultracet, tramadol/acetaminophen, Synapryn, Nucynta, belladonna/Opium, Opium, Seglentis, Roxybond, Hycodan, Hydromet, hydrocodone/homatropine, Tuzistra XR, hydrocodone/chlorpheniramine, M-END PE, Poly-Tussin AC, Capcof, Pro-Red AC, Histex-AC, Maxi-Tuss CD, promethazine/codeine, Promethazine VC/codeine, promethazine-phenylephrine-codeine, Rydex, Mar-Cof BP, Ninjacof-XG, Coditussin AC, Mar-Cof GG, Trymine CG, M-Clear WC, Codeine/Guaifenesin, G Tussin AC, Guaiatussin AC, Guaifenesin AC, Guaifenesin/Codeine, Virtussin A/C, Virtussin AC/ALC, Maxi-Tuss AC, Coditussin DAC, Virtussin DAC, Tuxarin ER, Tusnel C",
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Bone Formation Stimulating (Indiana) Prior Authorization Form - Community Plan
Last Published 07.10.2024
"Evenity, Tymlos, Forteo, Teriparatide",
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Cardiac Agents (Indiana) Prior Authorization Form - Community Plan
Last Published 09.30.2024
"Corlanor, Verquvo, Entresto, Camzyos, Ivabradine",
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Carisoprodol (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
"carisoprodol, Soma, Vanadom",
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Dificid (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
Dificid,
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Growth Hormone Adult (Indiana) Prior Authorization Form - Community Plan
Last Published 07.10.2024
"Genotropin, Genotropin Miniquick, Humatrope, Norditropin Flexpro, Nutropin AQ Nuspin, Omnitrope, Saizen, Saizenprep, Serostim, Zomacton, Sogroya",
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Growth Hormone Children (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
"Genotropin, Genotropin Miniquick, Humatrope, Norditropin Flexpro, Nutropin AQ Nuspin, Omnitrope, Saizen, Saizenprep, Serostim, Zomacton, Increlex, Skytrofa, Sogroya, Voxzogo, Ngenla",
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Hetlioz (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
"Hetlioz, tasimelteon, Hetlioz LQ ",
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Lucemyra (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
Lucemyra ,
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Narcolepsy Agents (Indiana) Prior Authorization Form - Community Plan
Last Published 09.30.2024
"Nuvigil, armodafinil, Provigil, modafinil, Sunosi, Wakix, Xyrem, sodium oxybate, Xywav ",
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Opioid - Request to Exceed MME Limit (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
"Belbuca, fentanyl patch, Hysingla ER, hydrocodone ER, Oxymorphone ER, Xtampza ER, Qdolo, tramadol, Conzip, tramadol ER, Butrans, buprenorphine patch, MS Contin, morphine ER, morphine CR, Nucynta ER, Oxycontin, Oxycodone ER, hydromorphone ER, methadone, methadose, butorphanol, acetaminophen/codeine, Fioricet/codeine, butalbital/acetaminophen/caffeine/codeine, ascomp/codeine, butalbital/aspirin/caffeine/codeine, Apadaz, Benzhydrocodone/acetaminophen, morphine, codeine, Lortab, hydrocodone/acetaminophen, Xodol, hydrocodone/ibuprofen, Trezix, acetaminophen/caffeine/dihydrocodeine, dilaudid, hydromorphone, oxycodone, Roxicodone, Percocet, Nalocet, Endocet, Prolate, Oxycodone/acetaminophen, oxycodone/aspirin, levorphanol, meperidine, Fortigan, oxymorphone, pentazocine/naloxone, Ultram, tramadol, Ultracet, tramadol/acetaminophen, Synapryn, Nucynta, belladonna/Opium, Opium, Seglentis, Roxybond, Hycodan, Hydromet, hydrocodone/homatropine, Tuzistra XR, hydrocodone/chlorpheniramine, M-END PE, Poly-Tussin AC, Capcof, Pro-Red AC, Histex-AC, Maxi-Tuss CD, promethazine/codeine, Promethazine VC/codeine, promethazine-phenylephrine-codeine, Rydex, Mar-Cof BP, Ninjacof-XG, Coditussin AC, Mar-Cof GG, Trymine CG, M-Clear WC, Codeine/Guaifenesin, G Tussin AC, Guaiatussin AC, Guaifenesin AC, Guaifenesin/Codeine, Virtussin A/C, Virtussin AC/ALC, Maxi-Tuss AC, Coditussin DAC, Virtussin DAC, Tuxarin ER, Tusnel C",
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Opioid with Concurrent Buprenorphine-Naloxone or Buprenorphine (Indiana) Prior Authorization Form - Community Plan
Last Published 07.10.2024
"Belbuca, fentanyl patch, Hysingla ER, hydrocodone ER, Oxymorphone ER, Xtampza ER, Qdolo, tramadol, Conzip, tramadol ER, Butrans, buprenorphine patch, MS Contin, morphine ER, morphine CR, Nucynta ER, Oxycontin, Oxycodone ER, hydromorphone ER, methadone, methadose, butorphanol, acetaminophen/codeine, Fioricet/codeine, butalbital/acetaminophen/caffeine/codeine, ascomp/codeine, butalbital/aspirin/caffeine/codeine, Apadaz, Benzhydrocodone/acetaminophen, morphine, codeine, Lortab, hydrocodone/acetaminophen, Xodol, hydrocodone/ibuprofen, Trezix, acetaminophen/caffeine/dihydrocodeine, dilaudid, hydromorphone, oxycodone, Roxicodone, Percocet, Nalocet, Endocet, Prolate, Oxycodone/acetaminophen, oxycodone/aspirin, levorphanol, meperidine, Fortigan, oxymorphone, pentazocine/naloxone, Ultram, tramadol, Ultracet, tramadol/acetaminophen, Synapryn, Nucynta, belladonna/Opium, Opium, Seglentis, Roxybond, Hycodan, Hydromet, hydrocodone/homatropine, Tuzistra XR, hydrocodone/chlorpheniramine, M-END PE, Poly-Tussin AC, Capcof, Pro-Red AC, Histex-AC, Maxi-Tuss CD, promethazine/codeine, Promethazine VC/codeine, promethazine-phenylephrine-codeine, Rydex, Mar-Cof BP, Ninjacof-XG, Coditussin AC, Mar-Cof GG, Trymine CG, M-Clear WC, Codeine/Guaifenesin, G Tussin AC, Guaiatussin AC, Guaifenesin AC, Guaifenesin/Codeine, Virtussin A/C, Virtussin AC/ALC, Maxi-Tuss AC, Coditussin DAC, Virtussin DAC, Tuxarin ER, Tusnel C",
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PCSK9 Inhibitors and Select Lipotropics (Indiana) Prior Authorization Form - Community Plan
Last Published 09.30.2024
"Juxtapid, Niacin ER, Praluent, Repatha",
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Prior Authorization Request Form for UnitedHealthcare Community Plan of Indiana
Last Published 04.07.2023
,
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Pulmonary Antihypertensives (Indiana) Prior Authorization Form - Community Plan
Last Published 11.26.2024
"Letairis, ambrisentan, Opsumit, Tracleer, bosentan, Revatio, sildenafil, Adcirca, tadalafil, Alyq, Tadliq, Orenitram, Tyvaso, Tyvaso DPI, Uptravi, Adempas, Liqrev, Ventavis, Winrevair, Opsynvi",
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Testosterones (Indiana) Prior Authorization Form - Community Plan
Last Published 07.10.2024
"Depo-Testosterone, testosterone cypionate, testosterone enanthate, Aveed, Testopel, Xyosted, Androderm, testosterone, Androgel, Testim, Vogelxo, Fortesta, Natesto, danazol, Jatenzo, Methitest, methyltestosterone, Tlando",
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Topical Agents (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
"Flector patch, Diclofenac epolamine patch, diclofenac topical solution, Licart",
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Uterine Disorders (Indiana) Prior Authorization Form - Community Plan
Last Published 07.10.2024
"Myfembree, Oriahnn, Orilissa",
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Vaginal Antimicrobials (Indiana) Prior Authorization Form - Community Plan
Last Published 07.22.2024
"Brexafemme, Vivjoa",