Cough and Cold, Opiate Combination (Maryland) Prior Authorization Form - Community Plan
Last Published 02.22.2022
Hydromet, Z-Tuss AC, Tuzistra XR, Tussicaps, M-End PE, Poly-tussin AC, Capcof, Pro-Red AC, Histex AC, Maxi-Tuss CD, Rydex, Mar-Cof BP, Ninjacof-XG, Coditussin AC, Mar-Cof CG, Trymine CG, Guiatuss AC, M-Clear WC, Lortuss, Coditussin DAC, Tusnel C, Virtussin, Tuxarin ER ,
Fertility Preservation (Maryland) Prior Authorization Form - Community Plan
Last Published 04.30.2024
"Pregnyl, Ovidrel, Novarel, Follistim AQ, Gonal-f, Goanl-f-RFF, Ganirelix, Lupron, Cetrotide, Menopur, chorionic gonadotropin, follitropin, leuprolide",
Opioid Products (Maryland) Prior Authorization Form - Community Plan
Last Published 02.22.2022
Apadaz, benzhydrocodone-acetaminophen, Lortab, hydrocodone-acetaminophen, Xodol, hydrocodone-ibuprofen, Dilaudid, hydromorphone, levorphanol, meperidine, morphine, oxycodone, Roxicodone, Oxaydo, Prolate, Endocet, Percocet, oxycodone-acetaminophen, Nalocet, oxycodone-aspirin, oxymorphone, pentazocine-naloxone, Nucynta, Trezix, acetaminophen-caffeine-dihydrocodeine, Fioricet-Codeine, butalbital-acetaminophen-caffeine-codeine, Ascomp/Codeine, butalbital-aspirin-caffeine-codeine, acetaminophen-codeine, codeine, Ultram, tramadol, Qdolo, Synapryn, Ultracet, tramadol-acetaminophen, belladonna alkaloids & opium suppositories, butorphanol, carisoprodol-aspirin-codeine, opium tincture, fentanyl, Hysingla ER, MS Contin, methadone, Methadose, Nucynta ER, Oxycontin ER, Xtampza ER, Duragesic, Zohydro ER, Conzip,