Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
-
Abilify (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.01.2018
-
Actemra (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.05.2019
-
Acthar Gel Prior Authorization Form - Community Plan
Last Modified 09.14.2018
-
Actimmune (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.07.2019
-
ADHD Products (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 09.17.2019
-
Afinitor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Afrezza (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.31.2019
-
Alecensa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
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
-
Alinia (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Alunbrig (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Ampyra (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Anthelmintics (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Anticonvulsants (AZ, FL, HI, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 09.25.2019
-
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
-
Antipsychotics (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 09.23.2019
-
Apokyn (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Aquadeks (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Aranesp (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Arcalyst (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.23.2019
-
Aricept 23mg [Donepezil] (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Arikayce (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.05.2019
-
Atripla (Florida, New Jersey, New York, Ohio, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Austedo (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 05.01.2019
-
Avonex (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Azole Antifungals (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.17.2018
-
Belbuca / Butrans (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 09.16.2019
-
Benlysta (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 09.20.2018
-
Benznidazole (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.31.2019
-
Berinert / Firazyr (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Bethkis (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Biktarvy (Florida Healthy Kids, NJ, New York - Essential Plan Only, OH, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Biltricide (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Bonjesta / Diclegis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Bosulif (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Braftovi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.25.2019
-
Brilinta & Effient (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 10.19.2018
-
Buphenyl (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Byetta / Victoza (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Cablivi (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.25.2019
-
Cabometyx (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.05.2019
-
Calcitonin Gene-Related Peptide [CGRP] (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.17.2019
-
Calquence (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.25.2019
-
Caprelsa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Carbaglu (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Cayston (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Celebrex Prior Authorization Form - Community Plan
Last Modified 09.27.2018
-
Cerdelga / Zavesca (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Cesamet / Marinol / Syndros (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Chantix (Florida Healthy Kids, HI, NY, RI) Prior Authorization Form - Community Plan
Last Modified 10.01.2018
-
Chemotherapy, Oral (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
-
Cholbam (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.29.2019
-
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
-
Cimzia (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.10.2019
-
Cinryze (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Ciprodex (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.10.2019
-
Colony Stimulating Factors (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.25.2019
-
Cometriq (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Complera Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Compound Medications Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
Constipation Agents (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 09.23.2019
-
Copaxone (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Copiktra (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Copper Chelating Agents (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.06.2019
-
Corlanor Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
Cosentyx (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.29.2019
-
Cotellic (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Cough and Cold, Opiate Combination (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 06.25.2018
-
Crestor (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Cystaran Prior Authorization Form - Community Plan
Last Modified 07.31.2019
-
Daliresp (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Daraprim (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 06.11.2019
-
Dificid (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
-
Doptelet (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.11.2019
-
DPP-4 Inhibitors (Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.29.2019
-
Dry Eye Disease [Restasis & Xiidra] (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Duexis and Vimovo (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.26.2019
-
Duopa (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Dupixent (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.30.2019
-
Effient (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 03.13.2019
-
Egrifta (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Elidel / Protopic (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.04.2018
-
Eliquis (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Elmiron (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Emflaza Prior Authorization Form - Community Plan
Last Modified 09.30.2019
-
Enbrel (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.30.2019
-
Endari Prior Authorization Form - Community Plan
Last Modified 12.20.2018
-
Enoxaparin (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
-
Entocort EC (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Entresto Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Epogen (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Erivedge (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Erleada (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
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
-
Eucrisa Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
Exjade (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.02.2018
-
Farydak (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Fenofibrate (AZ, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Fentanyl Immediate Release (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Firazyr (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Firdapse (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Forteo (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Fragmin (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
-
Galafold (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Gattex (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
-
General Non-Preferred Medication Prior Authorization Form - Community Plan
Last Modified 11.01.2018
-
Genvoya / Stribild (FL, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.20.2019
-
Gilenya (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
-
Gilotrif (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Gleevec (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
-
GLP-1 Agonist / Basal Insulin Combinations (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
GLP-1 Agonists (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 08.08.2018
-
Glumetza, Fortamet, Glucophage XR (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.04.2019
-
Gonadotropin-Releasing Hormone Agonists (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
Growth Hormone, Growth Stimulating Agents (HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.14.2019
-
H.P. Acthar Gel (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 01.23.2019
-
Haegarda (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Hemangeol (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.21.2018
-
Hemlibra (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.25.2019
-
Hepatitis C Medications (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 10.23.2018
-
Hetlioz Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
HIV Medications [Viread, Truvada, Viramune] (Florida Heathly Kids, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 06.09.2018
-
Human Chorionic Gonadotropin (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Humira (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.01.2019
-
Hycamtin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Ibrance (AZ, Florida Chip, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Iclusig (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
Idhifa (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
-
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
-
Ilaris (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.26.2019
-
Ilumya (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.29.2019
-
Imbruvica (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Increlex (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Inderal LA (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.24.2019
-
Ingrezza Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
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
-
Inhaled Corticosteroids [e.g. Flovent, Pulmicort, Asmanex] (HI, MD, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Inlyta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Insulin Pen (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
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
-
Insulins (FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 04.18.2019
-
Iressa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Iron Chelators [Exjade, Jadenu, Ferriprox] (AZ, Florida Healthy Kids, HI, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Irritable Bowel Syndrome - Diarrhea [e.g. Lotronex, Vibrezi] (AZ, Florida Healthy Kids, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Modified 09.25.2019
-
Isotretinoin - [Amesteem, Claravis, Myorisan, Zenatane and Absorica] - Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Itraconazole (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.29.2018
-
Jakafi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.11.2019
-
Jentadueto / Kombiglize XR / Onglyza / Tradjenta (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 05.03.2018
-
Juxtapid (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
Kalydeco (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.11.2019
-
Keveyis (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Kevzara (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.09.2019
-
Kineret (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.23.2019
-
Kisqali (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Kisqali Femara Co-Pack (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.23.2019
-
Korlym (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 06.10.2019
-
Kuvan (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
-
Kynamro (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
Lenvima (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Leukine (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
-
Lidocaine Patch (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Lokelma / Veltassa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.11.2019
-
Lonhala Magnair / Yupelri (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.14.2019
-
Lonsurf (AZ, FLCHP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.26.2019
-
Lorbrena (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.02.2019
-
Lovaza (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
-
Lovenox (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
-
Lucemyra (AZ, FL, HI, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Lupron (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.30.2018
-
Lynparza (AZ, FL CHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.23.2019
-
Lysteda (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Mekinist (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 08.12.2019
-
Mektovi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
-
Mepron (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Migranal Nasal Spray (AZ, FL CHIP, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 09.24.2019
-
Mozobil Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Mulpleta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Multaq (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Multiple Sclerosis (MS) Agents (FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Mytesi (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Namzaric (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.02.2018
-
Natpara (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Nerlynx (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Neulasta (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
-
Neupogen (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
-
Nexavar (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.14.2019
-
Ninlaro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.23.2019
-
Nityr (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Noctiva & Nocdurna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Northera (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Nuedexta (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Nuplazid (Arizona, Florida, Hawaii, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Ocaliva (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.31.2019
-
Odomzo (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Olumiant (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.24.2019
-
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
-
Opioid Products (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 09.16.2019
-
Optivar (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Orencia, Subcutaneous (Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Modified 09.30.2019
-
Orfadin (Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Orilissa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.25.2019
-
Orkambi (AZ, HI, MD, NJ, NY, OH, PA,. RI) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Osphena (FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorizatio Form - Community Plan
Last Modified 09.30.2019
-
Otezla (FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.04.2019
-
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
-
Oxervate (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Palynziq (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Panretin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Pomalyst (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Pradaxa (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Praluent (AZ, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
Prevymis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Procrit (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
-
Procysbi (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Progesterone - Non-Oral (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Progesterone, Oral Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Promacta (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.19.2019
-
Proton Pump Inhibitors (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
-
Provigil / Nuvigil (AZ, FL, HI, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.11.2019
-
Pulmonary Arterial Hypertension [Adcirca, Revatio, Uptravi] (Florida Healthy Kids, HI, MD, NJ, New York-Essential Plan Only, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.04.2019
-
Pulmozyme (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.05.2018
-
Ranexa (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Ravicti (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Re-Review Reconsideration Request Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
Rebif (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
-
Rectiv (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.17.2019
-
Regranex (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Relistor Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
Renvela Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
Repatha (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Revlimid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.07.2019
-
Rozerem (FLCHIP, HI, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.02.2019
-
Rubraca (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
-
Ruconest (AZ, FLCHIP, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 10.04.2019
-
Rydapt (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Samsca (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Sandostatin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.23.2019
-
Savaysa (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Sensipar (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
-
SGLT-2 Inhibitors (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 08.08.2018
-
Signifor (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
-
Siliq (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Simponi (FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.08.2019
-
Sivextro (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.06.2019
-
Somavert (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Soriatane (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Soriatane (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.23.2018
-
Specialty Medication Prior Authorization Cover Sheet (Rhode Island) - Community Plan
Last Modified 04.30.2018
-
Sprycel (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Stelara (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.29.2019
-
Stivarga (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.31.2018
-
Strensig (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
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
-
Suboxone / Subutex (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Sutent (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Symdeko (AZ, Florida Healthy Kids, HI, MD, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 11.06.2018
-
Symlin (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
Synagis (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 08.13.2018
-
Synagis Prior Authorization Form - Community Plan
Last Modified 10.08.2019
-
Synribo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Tafinlar (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Modified 09.27.2019
-
Tagrisso (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
Takhzyro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Taltz (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.29.2019
-
Talzenna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 09.30.2019
-
Tarceva (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Targretin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
Tasigna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
-
Tavalisse (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Tegsedi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
-
Temodar (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.28.2019
-
Test Strips (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.02.2019
-
Testosterone (FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.04.2019
-
Thalomid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.07.2019
-
Tibsovo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.03.2019
-
Tobi with Cover (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.24.2018
-
Tobramycin, Inhalation (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Topical Androgens (HI, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorizaton Form - Community Plan
Last Modified 01.29.2019
-
Topical NSAIDs (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.19.2019
-
Topical Retinoid Products (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Trelegy Ellipta (Florida Healthy Kids, MD, NJ, NY, OH, RI) Prior Authorziation Form - Community Plan
Last Modified 01.03.2019
-
Tremfya (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Triptans (Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.14.2019
-
Tykerb (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.31.2019
-
Tymlos Prior Authorization Form - Community Plan
Last Modified 04.05.2019
-
Uloric (AZ, HI, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Vaginal Progesterone (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
-
Valchlor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.10.2019
-
Vancocin (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Vancomycin (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
-
Vecamyl (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 12.27.2018
-
Vemlidy (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.09.2019
-
Venclexta (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.04.2019
-
Verzenio (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
VFend (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
-
Vitrakvi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
-
Vizimpro (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.04.2019
-
Votrient (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.19.2019
-
Vytorin (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.25.2018
-
Xalkori (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
-
Xarelto (FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.10.2019
-
Xeljanz / Xeljanz XR (FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.10.2019
-
Xenazine (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.30.2019
-
Xermelo (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 11.07.2018
-
Xifaxan (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.07.2019
-
Xolair (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 01.18.2019
-
Xopenex Respules (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Modified 12.28.2018
-
Xospata (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.16.2019
-
Xtandi (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Xuriden (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.31.2019
-
Xyrem (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 04.22.2019
-
Yonsa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
-
Zejula (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 10.23.2018
-
Zelboraf (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 07.09.2019
-
Zetia (Rhode Island) Prior Authorization Form - Community Plan
Last Modified 04.27.2018
-
Zolinza (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.05.2019
-
Zontivity (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.01.2019
-
Zydelig (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 01.23.2019
-
Zykadia (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Modified 01.04.2019
-
Zytiga (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 03.18.2019
-
Zyvox (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Modified 02.19.2019