Pennsylvania Community Plan Pharmacy Prior Authorization Forms

"Brand Adderall, generic amphetamine/dextroamphetamine, Brand Adderall XR, generic amphetamine/dextroamphetamine ER, Brand Intuniv, generic guanfacine ER, Brand Metadate ER, generic methylphenidate ER tab, generic methylphenidate ER (CD), Brand Concerta, generic methylphenidate ER OSM, Brand Ritalin, generic methylphenidate, generic methylphenidate ER (LA), Brand Ritalin LA, Brand Strattera, generic atomoxetine, Brand Vyvanse, Adhansia XR, Brand Adzenys XR-ODT, Brand Adzenys ER, generic amphetamine ER susp, Brand Aptensio XR, generic methylphenidate ER cap, Brand Cotempla XR-ODT, Brand Daytrana, Brand Desoxyn, generic methamphetamine, Brand Dexedrine, generic dextroamphetamine ER, Brand Dyanavel XR, Brand Evekeo, Evekeo ODT, generic amphetamine, Brand Focalin, generic dexmethylphenidate, Brand Focalin XR, generic dexmethylphenidate ER, Jornay PM, Brand Kapvay, generic clonidine ER, Brand Methylin, generic methylphenidate soln, Brand Mydayis, Brand Procentra, generic dextroamphetamine soln, Brand Quillichew ER, Brand Quillivant XR, Brand Zenzedi, generic dextroamphetamine, generic Relexxii, generic methylphenidate ER (OSM), Qelbree, Azstarys, generic methylphenidate patch ",

Butrans, buprenorphine, fentanyl patch, morphine, MS Contin, Xtampza ER, Belbuca, hydrocodone, Hysingla ER, hydromorphone ER, methadone, Methadose, Nucynta ER, Oxycodone ER, Oxycontin, oxymorphone, Tramadol, Conzip, Duragesic, Zohydro ER,

Actiq, fentanyl, acetaminophen/caffeine/dihydrocodeine, Trezix, acetaminophen/codeine, Apadaz, Benzhydrocodone/acetaminophen, Ascomp/codeine, butalbital/aspirin/caffeine/codeine, butalbital/acetaminophen/caffeine/codeine, Fioricet/codeine, codeine sulfate, meperidine, Dilaudid, hydromorphone, Dsuvia, Endocet, oxycodone/acetaminophen, Percocet, Fentora, hydrocodone/acetaminophen, Lortab, Xodol, hydrocodone/ibuprofen, Lazanda, levorphanol, morphine, Nalocet, Prolate, Nucynta, oxymorphone, oxycodone, Roxicodone, pentazocine/naloxone, Subsys, tramadol, Ultram, tramadol/acetaminophen, Ultracet, butorphanol, carisoprodol/aspirin/codeine, Oxaydo, Qdolo, Tramadol, Roxybond, Seglentis,

"Abilify Maintena, Abilify MyCite, Abilify, aripiprazole ODT, aripiprazole, Aristada, asenapine, Caplyta, chlorpromazine, clozapine, clozapine ODT, Clozaril, Fanapt, Fazaclo, fluphenazine, Geodon, Haldol, haloperidol decanoate, haloperidol, Invega, Invega Sustenna, Invega Trinza, Invega Hafyera, Latuda, loxapine, Lybalvi, molindone, olanzapine, olanzapine ODT, paliperidone, perphenazine, Perseris, pimozide, quetiapine, quetiapine ER, Rexulti, Risperdal Consta, Risperdal, risperidone ODT, risperidone, Saphris, Secuado, Seroquel, Seroquel XR, thioridazine, thiothixene, trifluoperazine, Versacloz, Vraylar, ziprasidone, Zyprexa, Zyprexa Zydis",

Abilify, Abilify Mycite, Adasuve, aripiprazole, Caplyta, chlorpromazine, clozapine, Clozaril, Fanapt, fluphenazine, Geodon, Haldol Decanoate, Invega ER, paliperidone ER, Latuda, molindone, Nuplazid, olanzapine, olanzapine/fluoxetine, Symbyax, perphenazine/amitriptyline, pimozide, Rexulti, Risperdal, risperidone, Saphris, asenapine, Secuado, Seroquel, Seroquel XR, thioridazine, thiothixene, Versacloz, Vraylar, ziprasidone, Zyprexa, Zyprexa Zydis, Abilify Maintena, Aristada ER, Aristada Initio, fluphenazine decanoate, haloperidol, haloperidol decanoate, haloperidol lactate, Invega Sustenna, Invega Trinza, loxapine, perphenazine, Perseris ER, quetiapine, quetiapine ER, Risperdal Consta, trifluoperazine, Zyprexa Relprevv, Equetro ,

Dupixent,

Adlyxin, Bydureon, Byetta, Ozempic, Rybelsus, Trulicity, Victoza,

"Genotropin, Humatrope, Norditropin, Omnitrope, Nutropin AQ, Saizen, Serostim, Zomacton, Zorbtive",

"Epclusa, Harvoni, ledipasvir/sofosbuvir, Sovaldi, Vosevi, Zepatier, Sofosbuvir/Velpatasvir ",

Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier,

"Janumet, Janumet XR, Januvia, Jentadueto, Tradjenta, Trulicity, Victoza, Ozempic, Nesina, alogliptan, Kazano, alogliptin-metformin, Jentadueto XR, Kombiglyze XR, Onglyza, Adlyxin, Bydureon BCise, Byetta, Rybelsus, Symlin Pen, Mounjaro, saxagliptin, saxagliptin-metformin ER",

Qvar RediHaler, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Alvesco, ArmonAir Digihaler ,

Synagis,

"Contrave, Adipex, phentermine, Qsymia, Saxenda, Wegovy, benzphetamine, diethylpropion, diethylpropion ER, Lomaira, phendimetrazine, phendimetrazine ER, Xenical, Orlistat, Zepbound",

Morphine ER, Duragesic, Fentanyl transdermal, Zohydro ER, Hydrocodone ER, Oxymorphone ER, Hydromorphone ER, Hysingla ER, MS Contin, Nucynta ER, Oxycontin, Oxycodone CR, Xtampza ER, Methadose, Methadone, Conzip, Tramadol ER Butorphanol, Carisoprodol-aspirin-codeine, Codeine, Acetaminophen-codeine, Butalbital-acetaminophen-caffeine-codeine, Fioricet/codeine, Ascomp/codeine, Butalbital-aspirin-caffeine-codeine, Morphine, Hydrocodone-acetaminophen, Lortab, Xodol, Hydrocodone-ibuprofen, Dilaudid, Hydromorphone, Oxycodone, Roxicodone, Oxaydo, Oxycodone-acetaminophen, Percocet, Prolate, Nalocet, Endocet, Oxycodone-aspirin, Oxymorphone, Pentazocine-naloxone, Ultram, Synapryn, Tramadol, Qdolo, Ultracet, Tramadol-acetaminophen, Nucynta, Meperidine, Levorphanol, Acetaminophen-caffeine-dihydrocodeine, Trezix, Belladonna alkaloids-opium, opium, Apadaz, Benzhydrocodone-acetaminophen ,

"Lucemyra, Suboxone, Zubsolv",

Steglatro, Segluromet, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, Synjardy XR, Farxiga, Xigduo XR,

Adderall, amphetamine-dextroamphetamine, Adderall XR, amphetamine-dextroamphetamine ER, Adzenys XR-ODT, Evekeo, amphetamine, clonidine ER, Concerta, Relexxi, methylphenidate ER, Cotempla XR ODT, Daytrana, Desoxyn, methylphenidate, Dexedrine, dextroamphetamine ER, Procentra, dextroamphetamine, Dyanavel XR, Focalin, dexmethylphenidate, Focalin XR, dexmethylphenidate ER, Intuniv ER, guanfacine ER, Methylin, methylphenidate, Ritalin LA, methylphenidate ER, Mydayis ER, Ritalin, Strattera, atomoxetine, Vyvanse, Zenzedi, dextroamphetamine, Quillichew ER, Quillivant XR, Aptensio XR, Jornay PM, Adhansia XR, Evekeo ODT, Wakix, Sunosi, Nuvigil, armodafinil, Provigil, modafinil, Kapvay, methamphetamine, Azstarys, Qelbree,

Suboxone, buprenorphine-naloxone, buprenorphine, Zubsolv, Bunavail,