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ADHD Products (HI, NJ, NY-CHIP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.01.2023
"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 ",
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Analgesics, Opioid Long-Acting (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 07.11.2023
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,
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Analgesics, Opioid Short-Acting (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 07.11.2023
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,
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Antipsychotics (NJ, NY-CHIP, NY-EPP, PA-CHIP) Prior Authorization Form - Community Plan
Last Published 04.01.2023
"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",
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Antipsychotics (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 02.23.2022
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 ,
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Dupixent (AZ, HI, MD, NJ, NY-CHIP, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.01.2023
Dupixent,
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GLP-1 Agonists (HI, MD, NJ, NY-CHIP, PA-CHIP) Prior Authorization Form - Community Plan
Last Published 04.01.2023
Adlyxin, Bydureon, Byetta, Ozempic, Rybelsus, Trulicity, Victoza,
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Growth Hormone (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 04.15.2022
"Genotropin, Humatrope, Norditropin, Omnitrope, Nutropin AQ, Saizen, Serostim, Zomacton, Zorbtive",
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Hepatitis C Agents (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 01.08.2024
"Epclusa, Harvoni, ledipasvir/sofosbuvir, Sovaldi, Vosevi, Zepatier, Sofosbuvir/Velpatasvir ",
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Hepatitis C Medications (Pennsylvania - CHIP Only) Prior Authorization Form - Community Plan
Last Published 02.24.2022
Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier,
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Hypoglycemics, Incretin Mimetics-Enhancers (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 08.30.2024
"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",
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Inhaled Corticosteroids (NY-CHIP, PA-CHIP) Prior Authorization Form - Community Plan
Last Published 02.25.2022
Qvar RediHaler, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Alvesco, ArmonAir Digihaler ,
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Medicaid Synagis Authorization Request Form - Community Plan
Last Published 04.01.2023
Synagis,
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Obesity Treatment Agents (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 09.09.2024
"Contrave, Adipex, phentermine, Qsymia, Saxenda, Wegovy, benzphetamine, diethylpropion, diethylpropion ER, Lomaira, phendimetrazine, phendimetrazine ER, Xenical, Orlistat, Zepbound",
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Opioid Products (NJ, NY-CHIP, NY-EPP, PA-CHIP) Prior Authorization Form - Community Plan
Last Published 04.01.2023
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 ,
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Opioid Use Disorder Treatments (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 02.29.2024
"Lucemyra, Suboxone, Zubsolv",
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SGLT-2 Inhibitors (HI, MD, NJ, NY-CHIP, PA-CHIP) Prior Authorization Form - Community Plan
Last Published 04.01.2023
Steglatro, Segluromet, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, Synjardy XR, Farxiga, Xigduo XR,
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Stimulants and Related Agents (Pennsylvania Medicaid Only) Prior Authorization Form - Community Plan
Last Published 04.29.2022
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,
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Suboxone / Subutex (Pennsylvania - CHIP Only) Prior Authorization Form - Community Plan
Last Published 02.24.2022
Suboxone, buprenorphine-naloxone, buprenorphine, Zubsolv, Bunavail,