Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
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Actemra (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Actimmune (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.07.2019
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Afinitor (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Afrezza (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Alecensa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Alfa Interferons [Intron A, Pegasys, Pegintron, Sylatron] (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Alinia (AZ, FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Alunbrig (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Ampyra (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Anthelmintics (Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Antipsoriatic Agents [e.g. Calcipotriene, Calcitriol] (AZ, HI, MD, NJ, NM, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Apokyn (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Aquadeks (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Aranesp (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
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Arcalyst (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Aricept 23mg [Donepezil] (AZ, HI, MD, NJ, NY, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Arikayce (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Austedo (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Avonex (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
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Azole Antifungals (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Balversa (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Belbuca / Butrans (Maryland) Prior Authorization Form - Community Plan
Last Modified 01.07.2020
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Benlysta (AZ, HI, LA, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Benznidazole (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Berinert / Firazyr (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.20.2018
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Bethkis (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.20.2018
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Biktarvy (MD, NJ, NYEPP only, PA-CHIP only, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2019
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Biltricide (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Bonjesta / Diclegis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Bosulif (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Braftovi (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Brilinta & Effient (AZ, Florida Healthy Kids, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Buphenyl (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Byetta / Victoza (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.27.2018
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Cablivi (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Cabometyx (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Calcitonin Gene-Related Peptide [CGRP] (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Calquence (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Caprelsa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Carbaglu (AZ, HI, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Cayston (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Celebrex Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Cerdelga / Zavesca (Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Cesamet / Marinol / Syndros (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Chemotherapy, Oral (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.27.2018
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Cholbam (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Cialis for Benign Prostatic Hyperplasia (AZ, HI, MD, NJ, NYEPP, PA-CHIP, RI)
Last Modified 01.03.2020
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Cimzia (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Cinryze (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Ciprodex (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Colony Stimulating Factors (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Cometriq (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Complera (MD, NJ, NYEPP only, PA-CHIP only, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2019
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Compound Medications Prior Authorization Form - Community Plan
Last Modified 01.21.2020
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Constipation Agents (Florida Healthy Kids, HI, MD, NJ, NY-not EPP, PA-CHIP) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Copaxone (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 09.28.2018
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Copiktra (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Copper Chelating Agents (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Corlanor Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Cosentyx (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Cotellic (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Cough and Cold, Opiate Combination (Maryland) Prior Authorization Form - Community Plan
Last Modified 07.06.2018
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Crestor (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Cystaran (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Daliresp (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 10.01.2018
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Daraprim (Maryland) Prior Authorization Form - Community Plan
Last Modified 11.07.2019
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Dificid (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Doptelet (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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DPP-4 Inhibitors (Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Dry Eye Disease [Restasis & Xiidra] (FL, HI, MD, NJ, NY, PA-CHIP) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Duexis and Vimovo (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Duopa (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Dupixent (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Egrifta (AZ, Florida Healthy Kids, MD, NJ, NY, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Elidel / Protopic (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Elmiron (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Emflaza Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Enbrel (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Endari Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Entocort EC (AZ, HI, MD, NJ, NY, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Entresto Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Epogen (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 10.02.2018
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Erivedge (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Erleada (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Erythropoietic Agents [e.g. Aranesp, Epogen, Procrit, Mircera] (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Eucrisa Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Exjade (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
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Farydak (AZ, Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Fenofibrate (AZ, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Fentanyl Immediate Release (AZ, Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Firazyr (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Firdapse (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Fortamet / Glumetza [Generics Only] (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Forteo (FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Fragmin (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
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Galafold (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Gattex (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
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General Non-Preferred Medication Prior Authorization Form - Community Plan
Last Modified 01.21.2020
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Genvoya / Stribild (MD, NJ, NYEPP only, PA-CHIP only, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2019
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Gilenya (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
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Gilotrif (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Gleevec (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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GLP-1 Agonist / Basal Insulin Combinations (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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GLP-1 Agonists (Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Glumetza, Fortamet, Glucophage XR (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.04.2019
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Gonadotropin-Releasing Hormone Agonists (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Growth Hormone, Growth Stimulating Agents (HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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H.P. Acthar Gel (AZ, FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Haegarda (Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Hemangeol (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Hemlibra (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Hepatitis C Medications (Maryland) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Hetlioz Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Human Chorionic Gonadotropin (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Humira (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Hycamtin (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Ibrance (AZ, Florida Chip, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Iclusig (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Idhifa (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Idiopathic Pulmonary Fibrosis [e.g. Esbriet, Ofev] (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Ilaris (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Ilumya (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Imbruvica (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Inbrija (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Increlex (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Inderal LA (Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Ingrezza Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Inhaled Corticosterioid / Long Acting Beta Agonist (LABA) Combinations [Advair, Dulera, Symbicort] (Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Inhaled Corticosteroids [e.g. Flovent, Pulmicort, Asmanex] (HI, MD, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Inlyta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Insulin Pen Needles and Syringes (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Insulins (FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Intuniv / Kapvay (Maryland) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Iressa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Irritable Bowel Syndrome - Diarrhea [e.g. Lotronex, Vibrezi] (AZ, Florida Healthy Kids, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Isotretinoin - [Amesteem, Claravis, Myorisan, Zenatane and Absorica] - Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Itraconazole (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Jakafi (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Jentadueto / Kombiglize XR / Onglyza / Tradjenta (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Juxtapid (AZ, FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Jynarque (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Kalydeco (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Keveyis (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Kevzara (Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Kineret (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.23.2019
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Kisqali (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Kisqali Femara Co-Pack (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Korlym (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Kuvan (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Kynamro (AZ, FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Lenvima (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Leukine (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Lidocaine Patch (AZ, HI, MD, NJ, NY, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Lokelma / Veltassa (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Lonhala Magnair / Yupelri (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Lonsurf (AZ, FLCHP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Lorbrena (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Lovaza (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Lovenox (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Lupron (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Lynparza (AZ, FL CHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Lyrica CR (Maryland) Prior Authorization Form - Community Plan
Last Modified 01.07.2020
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Lysteda (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Mavenclad (FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Medicaid Synagis Authorization Request - Community Plan
Last Modified 11.22.2019
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Mekinist (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Mektovi (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Mepron (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2020
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Migranal Nasal Spray (AZ, FL CHIP, HI, MD, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Mirvaso (AZ, FL, HI, MD, NJ, NY, PA-CHIP) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Mozobil Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Mulpleta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Multaq (AZ, HI, MD, NJ, NY, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Multiple Sclerosis (MS) Agents (FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Myalept (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Mytesi (AZ, Florida Healthy Kids, HI, MD, NJ, NY, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Namzaric (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Natpara (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Nerlynx (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Neulasta (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Neupogen (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Nexavar (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Ninlaro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Nityr (Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Noctiva & Nocdurna (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Northera (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Nuedexta (AZ, HI, MD, NJ, NM, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Ocaliva (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Odomzo (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Olumiant (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Omega [e.g. Lovaza, Epanova, Omtryg, Vascepa] (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Opioid Products (Maryland) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Optivar (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.20.2020
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Orencia, Subcutaneous (Florida Healthy Kids, HI, MD, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Orfadin (Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Orilissa (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Orkambi (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Osphena (FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 02.14.2020
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Otezla (FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Over Active Bladder (OAB) Agents (Florida HealthyKids, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island)) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Oxervate (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Palynziq (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Panretin (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Pomalyst (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Pradaxa (Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Praluent (AZ, HI, MD, NJ, NY, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Prevymis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Procrit (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Procysbi (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Progesterone - Non-Oral (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Progesterone, Oral Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Promacta (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Proton Pump Inhibitors (AZ, FLCHIP, HI, MA, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Pulmonary Arterial Hypertension [Adcirca, Revatio, Uptravi] (Florida Healthy Kids, HI, MD, NJ, NYCHIP, NYEPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Pulmozyme (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Ranexa Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Ravicti (AZ, HI, MD, NJ, NY, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Re-Review Reconsideration Request Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Rebif (Hawaii, Maryland, New York) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Rectiv (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Regranex (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Relistor Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Renvela Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Repatha (AZ, FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Revlimid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Rhofade (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Rubraca (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Ruconest (AZ, FLCHIP, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Rydapt (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Samsca (AZ, HI, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Sandostatin (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Sensipar (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
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SGLT-2 Inhibitors (Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Signifor (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 01.18.2019
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Siliq (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Simponi (FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Sivextro (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Somavert (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Soriatane (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Modified 01.04.2020
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Specialty Medication Prior Authorization Cover Sheet (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
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Sprycel (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Stelara (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Stivarga (AZ, FLCHIP, HI, MA, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Strensiq (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Sublingual Immunotherapy [e.g. Grastek, Orlair, Ragwitek] (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Sutent (AZ, Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Symdeko (AZ, Florida Healthy Kids, HI, MD, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Symlin (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Synribo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tafinlar (AZ, Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tagrisso (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Takhzyro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Taltz (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Talzenna (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tarceva (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Targretin (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tasigna (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tavalisse (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tegsedi (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Temodar (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Test Strips (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Testosterone (FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Thalomid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tibsovo (AZ, FLCHIP, HI, MA, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tobi with Cover (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
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Tobramycin, Inhalation (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Topical Androgens (HI, Florida Healthy Kids, MD, NJ, NY, PA, RI) Prior Authorizaton Form - Community Plan
Last Modified 12.31.2019
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Topical NSAIDs (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Topical Retinoid Products (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Trelegy Ellipta (FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorziation Form - Community Plan
Last Modified 12.31.2019
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Tremfya (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Triptans (FLCHIP, HI, MA, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tykerb (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Tymlos Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Uloric (AZ, HI, Florida Healthy Kids, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Vaginal Progesterone (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
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Valchlor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Vancocin (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Vancomycin (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Vecamyl (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Vemlidy (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Venclexta (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Verzenio (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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VFend (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
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Vitrakvi (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Vizimpro (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Votrient (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Vyndaqel / Vyndamax (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xalkori (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xarelto (FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xeljanz / Xeljanz XR (FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xenazine (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xermelo (AZ, HI, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xifaxan (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xolair (AZ, HI, LA, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xopenex Respules (AZ, HI, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xospata (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xtandi (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xuriden (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Xyrem (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Yonsa (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Zejula (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Zelboraf (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Zetia (HI, MD, NY) Prior Authorization Form - Community Plan
Last Modified 11.28.2018
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Zolinza (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Zontivity (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Zydelig (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Zykadia (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
-
Zytiga (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019
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Zyvox (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.31.2019