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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Abilify (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.01.2018
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Actemra (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.05.2019
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Acthar Gel Prior Authorization Form - Community Plan
Last Modified 09.14.2018
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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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ADHD Products (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 03.04.2019
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Afinitor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Afrezza (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.31.2019
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Alecensa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Alfa Interferons [Intron A, Pegasys, Pegintron, Sylatron] (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.18.2019
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Alinia (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Alunbrig (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Ampyra (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Anthelmintics (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Anticonvulsants (AZ, FL, HI, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.20.2019
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Antipsoriatic Agents [e.g. Calcipotriene, Calcitriol] (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.01.2019
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Antipsychotics (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 03.05.2019
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Apokyn (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Aquadeks (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Aranesp (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Arcalyst (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
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Aricept 23mg [Donepezil] (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Arikayce (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.05.2019
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Atripla (Florida, New Jersey, New York, Ohio, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Austedo (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 05.01.2019
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Avonex (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Azole Antifungals (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
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Belbuca / Butrans (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.18.2019
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Benlysta (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 09.20.2018
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Benznidazole (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.31.2019
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Berinert / Firazyr (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Bethkis (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Biktarvy (Florida Healthy Kids, NJ, New York - Essential Plan Only, OH, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Biltricide (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Bonjesta / Diclegis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Bosulif (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Braftovi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.25.2019
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Brilinta & Effient (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 10.19.2018
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Buphenyl (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Byetta / Victoza (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Cabometyx (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.05.2019
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Calcitonin Gene-Related Peptide [CGRP] (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.17.2019
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Calquence (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.25.2019
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Caprelsa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Carbaglu (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
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Cayston (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Celebrex Prior Authorization Form - Community Plan
Last Modified 09.27.2018
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Cerdelga / Zavesca (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
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Cesamet / Marinol / Syndros (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Chantix (Florida Healthy Kids, HI, NY, RI) Prior Authorization Form - Community Plan
Last Modified 10.01.2018
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Chemotherapy, Oral (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Cholbam (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.29.2019
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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
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Cimzia (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.10.2019
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Cinryze (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Ciprodex (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.10.2019
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Colony Stimulating Factors (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Cometriq (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Complera Prior Authorization Form - Community Plan
Last Modified 12.20.2018
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Compound Medications Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Copaxone (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Copiktra (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Copper Chelating Agents (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.06.2019
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Corlanor Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Cosentyx (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.29.2019
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Cotellic (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Cough and Cold, Opiate Combination (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 06.25.2018
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Crestor (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Cystaran Prior Authorization Form - Community Plan
Last Modified 07.31.2019
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Daliresp (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Daraprim (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 06.11.2019
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Dificid (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
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Doptelet (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.11.2019
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DPP-4 Inhibitors (Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.29.2019
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Dry Eye Disease [Restasis & Xiidra] (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Duopa (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
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Dupixent (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.18.2019
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Effient (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 03.13.2019
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Egrifta (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
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Elidel / Protopic (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.04.2018
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Eliquis (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Elmiron (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Emflaza Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Enbrel (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Endari Prior Authorization Form - Community Plan
Last Modified 12.20.2018
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Enoxaparin (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Entocort EC (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Entresto Prior Authorization Form - Community Plan
Last Modified 01.03.2019
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Epogen (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Erivedge (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Erleada (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Erythropoietic Agents [e.g. Aranesp, Epogen, Procrit, Mircera] (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Eucrisa Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Exjade (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
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Farydak (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
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Fenofibrate (AZ, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Fentanyl Immediate Release (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
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Firazyr (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
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Firdapse (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Forteo (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
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Fragmin (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Galafold (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Gattex (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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General Non-Preferred Medication Prior Authorization Form - Community Plan
Last Modified 11.01.2018
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Genvoya / Stribild (FL, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.20.2019
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Gilenya (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Gilotrif (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Gleevec (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
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GLP-1 Agonist / Basal Insulin Combinations (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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GLP-1 Agonists (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 08.08.2018
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Glumetza, Fortamet, Glucophage XR (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.31.2019
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Gonadotropin-Releasing Hormone Agonists (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Growth Hormone, Growth Stimulating Agents (HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.14.2019
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H.P. Acthar Gel (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 01.23.2019
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Haegarda (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Hemangeol (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.21.2018
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Hemlibra (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.25.2019
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Hepatitis C Medications (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 10.23.2018
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Hetlioz Prior Authorization Form - Community Plan
Last Modified 01.09.2019
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HIV Medications [Viread, Truvada, Viramune] (Florida Heathly Kids, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 06.09.2018
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Human Chorionic Gonadotropin (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Humira (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.15.2019
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Hycamtin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Ibrance (AZ, Florida Chip, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Iclusig (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Idhifa (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
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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
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Ilaris (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.26.2019
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Ilumya (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.29.2019
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Imbruvica (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Increlex (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Inderal LA (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.24.2019
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Ingrezza Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Inhaled Corticosterioid / Long Acting Beta Agonist (LABA) Combinations [Advair, Dulera, Symbicort] (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Inhaled Corticosteroids [e.g. Flovent, Pulmicort, Asmanex] (HI, MD, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Inlyta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
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Insulin Pen (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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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
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Insulins (FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 04.18.2019
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Iressa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
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Iron Chelators [Exjade, Jadenu, Ferriprox] (AZ, Florida Healthy Kids, HI, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Irritable Bowel Syndrome - Constipation (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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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 11.02.2018
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Isotretinoin - [Amesteem, Claravis, Myorisan, Zenatane and Absorica] - Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Itraconazole (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
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Jakafi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.11.2019
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Jentadueto / Kombiglize XR / Onglyza / Tradjenta (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
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Juxtapid (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Kalydeco (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
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Keveyis (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Kevzara (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.09.2019
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Kineret (Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Kisqali (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
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Kisqali Femara Co-Pack (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.23.2019
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Korlym (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.10.2019
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Kuvan (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Kynamro (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Lenvima (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Leukine (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Lidocaine Patch (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Lokelma / Veltassa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.11.2019
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Lonhala Magnair / Yupelri (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.14.2019
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Lonsurf (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
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Lorbrena (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.02.2019
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Lovaza (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Lovenox (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Lucemyra (AZ, FL, HI, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Lupron (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
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Lynparza Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Lysteda (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
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Mekinist (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 08.12.2019
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Mektovi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
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Mepron (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Migranal Nasal Spray (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Mozobil Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Mulpleta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
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Multaq (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Multiple Sclerosis (MS) Agents (FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Mytesi (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Namzaric (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
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Natpara (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
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Nerlynx (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Neulasta (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Neupogen (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Nexavar (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.14.2019
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Ninlaro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Nityr (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Noctiva & Nocdurna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Northera (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Nuedexta (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Nuplazid (Arizona, Florida, Hawaii, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
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Ocaliva (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.31.2019
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Odomzo (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Olumiant (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.19.2019
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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
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Opioid Products (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 02.01.2019
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Optivar (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Orencia, Subcutaneous (Florida Healthy Kids, HI, MD, NY (Non EPP), RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Orfadin (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Orilissa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.25.2019
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Orkambi (AZ, HI, MD, NJ, NY, OH, PA,. RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Otezla Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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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
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Oxervate (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Palynziq (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Panretin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Pomalyst (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Pradaxa (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Praluent (AZ, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Prevymis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Procrit (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Procysbi (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
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Progesterone - Non-Oral (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Progesterone, Oral Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Promacta (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.19.2019
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Proton Pump Inhibitors (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Provigil / Nuvigil (AZ, FL, HI, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.11.2019
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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
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Pulmozyme (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
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Ranexa (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
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Ravicti (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Re-Review Reconsideration Request Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Rebif (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Rectiv (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.17.2019
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Regranex (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Relistor Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Renvela Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Repatha (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Revlimid (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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Rozerem (AZ, Florida Healthy Kids, HI, NJ, NY, OH, PA, RI)
Last Modified 11.05.2018
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Rubraca (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
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Ruconest (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
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Rydapt (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
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Samsca (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Sandostatin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.23.2019
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Savaysa (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Sensipar (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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SGLT-2 Inhibitors (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 08.08.2018
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Signifor (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Siliq (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Simponi (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.30.2019
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Sivextro (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Somavert (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Soriatane (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Soriatane (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
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Specialty Medication Prior Authorization Cover Sheet (Rhode Island) - Community Plan
Last Modified 04.30.2018
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Sprycel (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Stelara (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.29.2019
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Stivarga (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
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Strensig (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
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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
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Suboxone / Subutex (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Sutent (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
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Symdeko (AZ, Florida Healthy Kids, HI, MD, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
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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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Synagis (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 08.13.2018
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Synagis Prior Authorization Form - Community Plan
Last Modified 07.02.2019
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Synribo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
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Tafinlar (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
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Tagrisso (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Takhzyro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Taltz (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.29.2019
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Talzenna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
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Tarceva (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Targretin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Tasigna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
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Tavalisse (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Tegsedi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
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Temodar (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
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Test Strips (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
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Thalomid (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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Tibsovo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
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Tobi with Cover (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
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Tobramycin, Inhalation (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Topical Androgens (HI, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorizaton Form - Community Plan
Last Modified 01.29.2019
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Topical NSAIDs (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.19.2019
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Topical Retinoid Products (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Trelegy Ellipta (Florida Healthy Kids, MD, NJ, NY, OH, RI) Prior Authorziation Form - Community Plan
Last Modified 01.03.2019
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Tremfya (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Triptans (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.14.2019
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Tykerb (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.31.2019
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Tymlos Prior Authorization Form - Community Plan
Last Modified 04.05.2019
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Uloric (AZ, HI, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Vaginal Progesterone (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Valchlor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
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Vancocin (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Vancomycin (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
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Vecamyl (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Vemlidy (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
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Venclexta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
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Verzenio (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
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VFend (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Vitrakvi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
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Vizimpro (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
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Votrient (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.19.2019
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Vytorin (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Xalkori (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
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Xarelto (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
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Xeljanz / Xeljanz XR (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
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Xenazine (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
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Xermelo (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
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Xifaxan (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.07.2019
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Xolair (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 01.18.2019
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Xopenex Respules (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
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Xospata (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
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Xtandi (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
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Xuriden (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.31.2019
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Xyrem (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.22.2019
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Yonsa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
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Zejula (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.23.2018
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Zelboraf (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.09.2019
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Zetia (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
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Zolinza (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
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Zontivity (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.01.2019
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Zydelig (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.23.2019
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Zykadia (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
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Zytiga (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
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Zyvox (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.19.2019