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ADHD Products (HI, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 02.08.2021
"Brand Adderall, generic amphetamine/dextroamphetamine, Brand Adderall XR, generic amphetamine/dextroamphetamine ER, Brand Intuniv, generic guanfacine ER, Brand Metadate ER, generic methylphenidate ER tab, generic methylphenidate ER (CD), Brand Concerta, generic methylphenidate ER OSM, Brand Ritalin, generic methylphenidate, generic methylphenidate ER (LA), Brand Ritalin LA, Brand Strattera, generic atomoxetine, Brand Vyvanse, Adhansia XR, Brand Adzenys XR-ODT, Brand Adzenys ER, generic amphetamine ER susp, Brand Aptensio XR, generic methylphenidate ER cap, Brand Cotempla XR-ODT, Brand Daytrana, Brand Desoxyn, generic methamphetamine, Brand Dexedrine, generic dextroamphetamine ER, Brand Dyanavel XR, Brand Evekeo, Evekeo ODT, generic amphetamine, Brand Focalin, generic dexmethylphenidate, Brand Focalin XR, generic dexmethylphenidate ER, Jornay PM, Brand Kapvay, generic clonidine ER, Brand Methylin, generic methylphenidate soln, Brand Mydayis, Brand Procentra, generic dextroamphetamine soln, Brand Quillichew ER, Brand Quillivant XR, Brand Zenzedi, generic dextroamphetamine, generic Relexxii, generic methylphenidate ER (OSM) ",
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Antipsychotics (Rhode Island) Prior Authorization Form - Community Plan
Last Published 06.02.2020
Abilify Maintena, Abilify MyCite, Abilify, aripiprazole ODT, aripiprazole oral solution, aripiprazole, Aristada, Caplyta, clozapine, Clozaril, Fanapt, Geodon, Invega Sustenna, Invega, Invega Trinza, Latuda, olanzapine ODT, olanzapine, paliperidone ER, Perseris, quetiapine ER, quetiapine, Rexulti, Risperdal Consta, Risperdal oral solution, Risperdal, risperidone ODT, risperidone oral solution, risperidone, Saphris, Secuado, Seroquel XR, Seroquel, Versacloz, Vraylar, ziprasidone, Zyprexa Zydis, Zyprexa,
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Calcitonin Gene-Related Peptide (CGRP) Antagonists [Aimovig, Emgality, Ajovy] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Celebrex (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Crestor (HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 07.01.2020
"Crestor, rosuvastatin",
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DPP-4 Inhibitors (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Dry Eye Disease (Rhode Island) Prior Authorization Form - Community Plan
Last Published 06.02.2020
Cequa, Restasis, Restasis Multidose, Xiidra,
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Dupixent (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.28.2020
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GLP-1 Agonists (Rhode Island) Prior Authorization Form - Community Plan
Last Published 06.02.2020
Adlyxin, Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza,
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Gonadotropin-Releasing Hormone Agents (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 06.11.2020
"leuprolide acetate, Lupaneta Pack, Lupron Depot, Lupron Depot Ped, Triptodur",
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Hepatitis C Medications (Rhode Island) Prior Authorization Form - Community Plan
Last Published 06.02.2020
"Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier",
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Humira (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.30.2020
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Ingrezza (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Inhaled Corticosteroid / Long Acting Beta Agonist (LABA) Combinations [Advair, Dulera, Symbicort] (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 08.06.2020
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Inhaled Corticosteroids (HI, MD, NJ, NY, NY-EPP, RI) Prior Authorization Form - Community Plan
Last Published 07.22.2020
Alvesco, Asmanex HFA, Asmanex Twisthaler, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler,
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Omega [Lovaza, Vascepa] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.02.2020
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Opioid Products (Rhode Island) Prior Authorization Form - Community Plan
Last Published 06.03.2020
Arymo, Conzip, Dolophine, Duragesic, fentanyl patch, hydrocodone ER, hydromorphone ER, Hysingla ER, Kadian, methadone, Methadose, Morphabond ER, morphine sulfate ER, MS Contin, Nucynta ER, oxycodone ER, oxymorphone ER, Oxycontin, tramadol ER, Xtampza ER, Zohydro ER, acetaminophen w/codeine, acetaminophen-caffeine-dihydrocodeine, Apadaz, Ascomp/Codeine, belladonna alkaloids & opium suppositories, benzhydrocodone-acetaminophen, butalbital-acetaminophen-caffeine w/codeine, butalbital-aspirin-caffeine w/codeine, butorphanol nasal spray, carisoprodol-aspirin-codeine, codeine sulfate, Dilaudid, Dvorah, Endocet, Fioricet/Codeine, Fiorinal/Codeine, Fortigan, hydrocodone-acetaminophen, hydrocodone-ibuprofen, hydromorphone, levorphanol, Lorcet HD, Lorcet Plus, Lorcet, Lortab, meperidine, morphine, Nalocet, Norco, Nucynta, Opana, opium tincture, Oxaydo, oxycodone, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, oxymorphone, pentazocine w/naloxone, Percocet, Primlev, Roxicodone, Synapryn, tramadol, tramadol-acetaminophen, Trezix, Tylenol w/Codeine, Ultracet, Ultram, Vicodin HP, Xodol,
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Praluent (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 05.07.2020
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Repatha (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 05.07.2020
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SGLT-2 Inhibitors (Rhode Island) Prior Authorization Form - Community Plan
Last Published 06.02.2020
Steglatro, Segluromet, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, Synjardy XR, Farxiga, Xigduo XR,
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Suboxone / Subutex (Rhode Island) Prior Authorization Form - Community Plan
Last Published 06.02.2020
Suboxone sublingual film, buprenorphine sublingual tablet, Zubsolv, Bunavail, buprenorphine/naloxone,
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Test Strips (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.14.2020
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Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) [diclofenac gel/patch/solution, Flector, Pennsaid] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.14.2020
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Topical Retinoids [Epiduo, Retin-A, Tazorac] (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.14.2020
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Xarelto (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.17.2020
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Xifaxan (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.17.2020
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Xolair (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.23.2020
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