Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
-
Actemra (Florida Healthy Kids, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 09.14.2018
-
Actimmune (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.07.2019
-
Afinitor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Alecensa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Alfa Interferons [Intron A, Pegasys, Pegintron, Sylatron] (Florida Healthy Kids, HI, MD, NJ, NY, OH) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Alinia Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Alunbrig (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Ampyra (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Anthelmintics (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Antipsoriatic Agents [e.g. Calcipotriene, Calcitriol] (AZ, HI, MD, NJ, NM, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Apokyn (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Aranesp (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
-
Arcalyst (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
-
Aricept 23mg [Donepezil] (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Atypical Antipsychotics Prior Authorization Form - Community Plan
Last Modified 04.24.2018
-
Austedo (AZ, Florida Healthy Kids, HI, MD, NJ, NY, NYEPP, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
-
Avonex (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
-
Azole Antifungals (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
-
Belbuca/Butrans (Maryland) Prior Authorization Form - Community Plan
Last Modified 10.25.2018
-
Benlysta (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 09.20.2018
-
Benznidazole (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 09.20.2018
-
Berinert / Firazyr (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.20.2018
-
Bethkis (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.20.2018
-
Bonjesta / Diclegis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Bosulif (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 09.27.2018
-
Brilinta & Effient (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 10.19.2018
-
Buphenyl, Oral (AZ, HI, LA, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Byetta / Victoza (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.27.2018
-
Cabometyx (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.27.2018
-
Calcitonin Gene-Related Peptide [CGRP] (AZ, Florida Healthy Kids, HI, MD, NY, NJ, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.19.2018
-
Calquence Prior Authorization Form - Community Plan
Last Modified 09.27.2018
-
Caprelsa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Carbaglu (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Celebrex Prior Authorization Form - Community Plan
Last Modified 09.27.2018
-
Cerdelga / Zavesca (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Cesamet & Marinol (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Communiy Plan
Last Modified 09.27.2018
-
Chemotherapy, Oral (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.27.2018
-
Cialis for Benign Prostatic Hyperplasia (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 09.27.2018
-
Cimzia (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Cinryze (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Ciprodex (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI)
Last Modified 09.28.2018
-
Colony Stimulating Factors Prior Authorization Form - Community Plan
Last Modified 09.28.2018
-
Cometriq (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Complera Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Compound Medications Prior Authorization Form - Community Plan
Last Modified 09.28.2018
-
Copaxone (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.28.2018
-
Copper Chelating Agents (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Corlanor Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Cosentyx Prior Authorization Form - Community Plan
Last Modified 09.28.2018
-
Cotellic Prior Authorization Form - Community Plan
Last Modified 09.28.2018
-
Cough and Cold, Opiate Combination (Maryland) Prior Authorization Form - Community Plan
Last Modified 07.06.2018
-
Crestor Prior Authorization Form - Community Plan
Last Modified 11.27.2018
-
Cystaran Prior Authorization Form - Community Plan
Last Modified 10.01.2018
-
Daliresp (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 10.01.2018
-
Daraprim (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.01.2018
-
Dificid (AZ, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
DPP-4 Inhibitors (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Dry Eye Disease [Restasis & Xiidra] (AZ, HI, MD, NJ, NY, OH, PA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Duopa (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Dupixent Prior Authorization Form - Community Plan
Last Modified 10.02.2018
-
Egrifta (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Elidel / Protopic (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Emflaza Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Enbrel Prior Authorization Form - Community Plan
Last Modified 10.02.2018
-
Endari Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Entocort EC (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Entresto Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Epogen (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 10.02.2018
-
Erivedge Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Erleada (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Erythropoietic Agents [e.g. Aranesp, Epogen, Procrit, Mircera] (AZ, HI, MD, NJ, NY, OH, PA, RI, and WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Eucrisa Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Exjade (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Farydak (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Fenofibrate (AZ, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Fentanyl Immediate Release (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Firazyr (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Forteo (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Fragmin (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Gattex (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
General Non-Preferred Medication Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Genvoya Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Gilenya (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Gilotrif (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Gleevec Prior Authorization Form - Community Plan
Last Modified 12.21.2018
-
GLP-1 Agonist / Basal Insulin Combinations Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
GLP-1 Agonists (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Glumetza, Fortamet, Glucophage XR (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Gonadotropin-Releasing Hormone Agonists (AZ, HI, LA, MD, NJ, NY (Non-Essential), OH, PA, RI WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Gout Medications Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Growth Hormone Medication Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
H.P. Acthar Gel (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 10.23.2018
-
Haegarda (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Hemangeol (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.21.2018
-
Hemlibra (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Hepatitis C Medications (Maryland) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
-
Hetlioz Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Human Chorionic Gonadotropin (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Humira Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Hycamtin Prior Authorization Form - Community Plan
Last Modified 12.21.2018
-
Ibrance (AZ, Florida Chip, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Iclusig Prior Authorization Form - Community Plan
Last Modified 12.21.2018
-
Idhifa (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.26.2018
-
Idiopathic Pulmonary Fibrosis [e.g. Esbriet, Ofev] (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.26.2018
-
Ilaris Prior Authorization Form - Community Plan
Last Modified 12.26.2018
-
Imbruvica (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Impavido Prior Authorization Form - Community Plan
Last Modified 12.26.2018
-
Increlex (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Inderal LA Prior Authorization Form - Community Plan
Last Modified 11.28.2018
-
Ingrezza Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Inhaled Corticosterioid / Long Acting Beta Agonist (LABA) Combinations [Advair, Dulera, Symbicort] (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Inhaled Corticosteroids [e.g. Flovent, Pulmicort, Asmanex] (HI, MD, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Inlyta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Insulin Pen Needles and Syringes (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Insulins (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Intuniv / Kapvay (Maryland) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
-
Iressa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Irritable Bowel Syndrome - Constipation (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Irritable Bowel Syndrome - Diarrhea [e.g. Lotronex, Vibrezi] (AZ, Florida Healthy Kids, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Isotretinoin - [Amesteem, Claravis, Myorisan, Zenatane and Absorica] - Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Itraconazole (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Jakafi (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Jentadueto / Kombiglize XR / Onglyza / Tradjenta (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Kalydeco (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Keveyis (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Kevzara (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Kineret (Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Kisqali (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Kuvan (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Kynamro (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lenvima (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Leukine (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lidocaine Patch (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lonsurf (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Lovaza (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lovenox (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lupron (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lynparza Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lyrica Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lysteda (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Mekinist (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Mepron (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Migranal Nasal Spray (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Mirvaso Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Mozobil Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Mulpleta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Multaq (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Multiple Sclerosis Agents [e.g. Copaxone, Gilenya, Tecfidera] (Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorziation Form - Community Plan
Last Modified 11.02.2018
-
Mytesi (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Namzaric (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Natpara (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Nerlynx (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Neulasta (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Neupogen (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Nexavar (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.14.2019
-
Ninlaro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Nityr (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Northera (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Nuedexta (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Ocaliva (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Odomzo (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Omega [e.g. Lovaza, Epanova, Omtryg, Vascepa] (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Opioid Medications (Maryland) Prior Authorization Form - Community Plan
Last Modified 10.22.2018
-
Optivar (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Orencia, Subcutaneous (Florida Healthy Kids, HI, MD, NY (Non EPP), RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Orfadin (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Orkambi (AZ, HI, MD, NJ, NY, OH, PA,. RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Otezla Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Over Active Bladder (OAB) Agents (Florida HealthyKids, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island)) Prior Authorization Form - Community Plan
Last Modified 12.26.2018
-
Palynziq (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Panretin Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Pomalyst (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Pradaxa (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Praluent (AZ, HI, LA, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Prevymis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Procrit (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Procysbi (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Progesterone - Non-Oral (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Progesterone, Oral Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Promacta (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Proton Pump Inhibitors (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Pulmonary Arterial Hypertension [Adcirca, Revatio, Uptravi] (Florida Healthy Kids, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Pulmozyme (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Ranexa Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Ravicti (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Re-Review Reconsideration Request Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Rebif (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Rectiv (AZ, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Regranex (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Relistor Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Renvela Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Repatha (AZ, HI, LA, MD, NJ, NY) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Revlimid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.07.2019
-
Rhofade (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Rubraca (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Ruconest (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Rydapt (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Samsca (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Sandostatin (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Sensipar (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
SGLT-2 Inhibitors (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Signifor (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Siliq (Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Simponi (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Sivextro Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Somavert (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Soriatane (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Specialty Medication Prior Authorization Cover Sheet (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Sprycel (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Stelara (Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Stivarga (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Strensig (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Sublingual Immunotherapy [e.g. Grastek, Orlair, Ragwitek] (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Sutent (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Symdeko (AZ, Florida Healthy Kids, HI, MD, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Symlim / Symlin Pen (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Synagis Prior Authorization Form - Community Plan
Last Modified 11.20.2018
-
Synribo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Tafinlar (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Tagrisso (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Taltz (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Tarceva (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Targretin (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Tasigna (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Temodar (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.23.2018
-
Test Strips (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Thalomid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.07.2019
-
Tibsovo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Tobi with Cover (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Tobramycin, Inhalation (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Topical NSAIDs (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Topical Retinoid Products (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Topical Testosterone (AZ, HI, LA, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Trelegy Ellipta (Florida Healthy Kids, MD, NJ, NY, OH, RI) Prior Authorziation Form - Community Plan
Last Modified 01.03.2019
-
Tremfya (HI, MD, NJ, NY (Non-Essential), OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Triptans (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.14.2019
-
Tykerb (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Tymlos Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Uloric (AZ, HI, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Vaginal Progesterone (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Valchlor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Vancocin (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Vecamyl (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Veltassa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Vemlidy (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Venclexta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Verzenio (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
VFend (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Votrient (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xalkori (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xarelto (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xeljanz, Xeljanz XR (Florida Healthy Kids, HI, MD, NJ, NY (Non EPP), OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xenazine (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xermelo (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xifaxan (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xolair (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 10.31.2018
-
Xopenex Respules (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Xtandi (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Xuriden (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xyrem (AZ, HI, LA, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Zejula (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.23.2018
-
Zelboraf (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.05.2018
-
Zetia (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.28.2018
-
Zolinza (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Zydelig (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Zykadia (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Zytiga (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Zyvox (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018