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 Published 05.01.2018
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Actemra (HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Acthar Gel Prior Authorization Form - Community Plan
Last Published 09.14.2018
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Actimmune (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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ADHD Products (Rhode Island) Prior Authorization Form - Community Plan
Last Published 09.17.2019
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Afinitor (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Afrezza (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Alecensa (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Alfa Interferons [Intron A, Pegasys, PegIntron, Sylatron] (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Alinia (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Alunbrig (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Ampyra (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Anthelmintics [Albenza, albendazole, Emverm ] (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Anticonvulsants [Briviact, Sympazan, Sabril] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Antipsoriatic Agents [Calcipotriene cream/ointment, Calcitrol ointment] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Antipsychotics (Rhode Island) Prior Authorization Form - Community Plan
Last Published 09.23.2019
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Apokyn (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Aquadeks (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Aranesp (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Arcalyst (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Aricept 23mg [Donepezil 23mg] (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Arikayce (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
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Atripla (MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Austedo (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Avonex (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Azelastine Ophthalmic Solution (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Azole Antifungals [Onmel, Noxafil, Sporanox, Vfend] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Balversa (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Belbuca / Butrans (Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.20.2020
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Benlysta (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Benznidazole (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Berinert (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Berinert / Firazyr (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Bethkis (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Biktarvy (MD, NJ, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Biltricide (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Bonjesta / Diclegis (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Bosulif (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Braftovi (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Brilinta / Effient (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Buphenyl (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Byetta / Victoza (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Cablivi (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Cabometyx (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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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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Calquence (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Caprelsa (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Carbaglu (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Cayston (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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Cerdelga / Zavesca (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Cesamet / Marinol / Syndros (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Chantix (HI, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Chemotherapy, Oral (Rhode Island) Prior Authorization Form - Community Plan
Last Published 05.03.2018
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Cholbam (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Cialis for Benign Prostatic Hyperplasia (AZ, HI, MD, NJ, NY-CHIP, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Cimzia (HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Cinryze (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2020
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Ciprodex (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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Colony Stimulating Factors (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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Cometriq (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.20.2020
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Complera (MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community PlaN
Last Published 03.20.2020
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Compound Medications Prior Authorization Form - Community Plan
Last Published 01.21.2020
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Constipation Agents (Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Copaxone (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Copiktra (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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Copper Chelating Agents [e.g., Depen, Cuprimine, Syprine] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Corlanor (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Cosentyx (HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Cotellic (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Cough and Cold, Opiate Combination (Rhode Island) Prior Authorization Form - Community Plan
Last Published 06.25.2018
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Crestor (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Cystaran (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Daliresp (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Daliresp (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Daraprim (Rhode Island) Prior Authorization Form - Community Plan
Last Published 11.27.2019
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Daurismo (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Descovy (MD, NJ, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Dificid (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Doptelet (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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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 [Restasis & Xiidra] (Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
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Duexis / Vimovo (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Duopa (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Dupixent (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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Effient (Rhode Island) Prior Authorization Form - Community Plan
Last Published 03.13.2019
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Egrifta (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Elidel / Protopic (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Elidel / Protopic (Rhode Island) Prior Authorization Form - Community Plan
Last Published 05.04.2018
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Eliquis (Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
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Elmiron (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Enbrel (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Endari (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Enoxaparin (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.25.2018
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Entocort EC (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Entresto (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Epaned (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Epogen (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Erivedge (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Erleada (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Erythropoietic Agents [e.g. Aranesp, Epogen, Procrit, Mircera] (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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Esbriet / Ofev (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Eucrisa (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Exjade (Rhode Island) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Farydak (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Fasenra (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Fenofibrate (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Fentanyl Immediate-Release (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Firazyr (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Firdapse (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Fortamet / Glumetza [Generics Only] (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Forteo (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.23.2020
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Fragmin (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.30.2018
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Galafold (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Gattex (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Gattex (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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General Non-Preferred Medication (Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.21.2020
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Genvoya / Stribild (MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community PlaN
Last Published 03.24.2020
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Gilenya (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.30.2018
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Gilotrif (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Gleevec (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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GLP-1 Agonist / Basal Insulin Combinations [Soliqua, Xultophy] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.20.2020
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GLP-1 Agonists (Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Glumetza, Fortamet, Glucophage XR (FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 10.04.2019
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Gonadotropin-Releasing Hormone Agonists (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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Growth Hormone, Growth Stimulating Agents (HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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H.P. Acthar Gel (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2020
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Haegarda (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Hemangeol (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Hemlibra (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Hepatitis C Medications (Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.16.2019
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Hetlioz (HI, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Human Chorionic Gonadotropin [Novarel, Ovidrel, Pregnyl] (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Humira (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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Hycamtin (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Ibrance (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Iclusig (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Idhifa (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Ilaris (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Ilumya (HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community PlanOpens in a new window
Last Published 03.24.2020
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Imbruvica (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Inbrija (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Increlex (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Inderal LA (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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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 Corticosterioid / 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 03.24.2020
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Inhaled Corticosteroids [e.g. Flovent, Pulmicort, Asmanex] (HI, MD, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2020
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Inlyta (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Inrebic (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Insulin Pen (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Insulin Pen Needles and Syringes (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Insulins (FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
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Iressa (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Iron Chelators [Exjade, Jadenu, Ferriprox] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Irritable Bowel Syndrome(IBS) - Diarrhea [ Lotronex, alosetron, Viberzi] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Isotretinoin [Absorica, Claravis, Zenatane] (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.24.2020
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Itraconazole (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Jakafi (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Jentadueto / Kombiglize XR / Onglyza / Tradjenta (Rhode Island) Prior Authorization Form - Community Plan
Last Published 05.03.2018
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Juxtapid (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Jynarque (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Kalydeco (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Keveyis (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Kevzara (HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Kineret (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Kisqali (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Kisqali Femara Co-Pack (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Korlym (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Kuvan (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2020
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Kuvan (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.24.2018
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Kynamro (AZ, FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
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Lenvima (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Leukine (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.24.2018
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Lidocaine Patch (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Lokelma / Veltassa (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Lonhala Magnair / Yupelri (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Lonsurf (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Lorbrena (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Lovaza (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.24.2018
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Lovenox (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Lovenox (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.24.2018
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Lucemyra (AZ, HI, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Lupron (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.30.2018
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Lynparza (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Lysteda (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Mavenclad (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Medicaid Synagis Authorization Request - Community Plan
Last Published 11.22.2019
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Mekinist (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Mektovi (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Mepron (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Migranal Nasal Spray (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Mozobil (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Mulpleta (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Multaq (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Multiple Sclerosis (MS) Agents (HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Myalept (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Mytesi (AZ, HI, MD, NJ, NY, NY-EPP, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Published 03.31.2020
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Namzaric (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Natpara (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
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Nerlynx (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Neulasta (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.25.2018
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Neupogen (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.25.2018
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Nexavar (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Ninlaro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Nityr (Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
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Noctiva & Nocdurna (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Northera (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Nuedexta (AZ, HI, MD, NJ, NM, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Nuplazid (Arizona, Florida, Hawaii, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Ocaliva (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Odomzo (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Olumiant (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Omega [e.g. Lovaza, Epanova, Omtryg, Vascepa] (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Opioid Products (Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.24.2020
-
Optivar (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.20.2020
-
Orencia, Subcutaneous (Florida Healthy Kids, HI, MD, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Orfadin (Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Orilissa (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Orkambi (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Osphena (FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 02.14.2020
-
Otezla (FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Over Active Bladder (OAB) Agents (Florida HealthyKids, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island)) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Oxervate (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Palynziq (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Panretin (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Pomalyst (AZ, FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Pradaxa (Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Praluent (AZ, HI, MD, NJ, NY, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Prevymis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Procrit (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Procysbi (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
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Progesterone - Non-Oral (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Progesterone, Oral Prior Authorization Form - Community Plan
Last Published 12.31.2019
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Promacta (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Proton Pump Inhibitors (AZ, FLCHIP, HI, MA, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Provigil / Nuvigil (AZ, FL, HI, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Pulmonary Arterial Hypertension [Adcirca, Revatio, Uptravi] (Florida Healthy Kids, HI, MD, NJ, NYCHIP, NYEPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
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Pulmozyme (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
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Ranexa (Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.03.2019
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Ravicti (AZ, HI, MD, NJ, NY, PA-CHIP, RI, WA) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Re-Review Reconsideration Request Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Rebif (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Rectiv (AZ, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Regranex (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Relistor Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Renvela Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Repatha (AZ, FL, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Revlimid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Rozerem (FLCHIP, HI, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Rubraca (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Ruconest (AZ, FLCHIP, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Rydapt (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Samsca (AZ, HI, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Sandostatin (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Savaysa (Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
-
Sensipar (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.23.2018
-
SGLT-2 Inhibitors (Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.16.2019
-
Signifor (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.23.2018
-
Siliq (FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Simponi (FLCHIP, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Sivextro (AZ, FL, HI, MD, NJ, NY, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Somavert (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania-CHIP, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Soriatane (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 01.04.2020
-
Soriatane (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.23.2018
-
Specialty Medication Prior Authorization Cover Sheet (Rhode Island) - Community Plan
Last Published 04.30.2018
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Spravato (FLCHIP, HI, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Sprycel (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Stelara (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Stivarga (AZ, FLCHIP, HI, MA, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Strensiq (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Sublingual Immunotherapy [e.g. Grastek, Orlair, Ragwitek] (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Suboxone / Subutex (Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
-
Sutent (AZ, Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Symdeko (AZ, Florida Healthy Kids, HI, MD, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Symlin (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
-
Synagis (Rhode Island) Prior Authorization Form - Community Plan
Last Published 08.13.2018
-
Synribo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tafinlar (AZ, Florida Healthy Kids, HI, MD, NY, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tagrisso (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Takhzyro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Taltz (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Talzenna (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tarceva (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Targretin (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tasigna (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tavalisse (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tegsedi (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Temodar (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Test Strips (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Testosterone (FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Thalomid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tibsovo (AZ, FLCHIP, HI, MA, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tobi with Cover (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.24.2018
-
Tobramycin, Inhalation (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Topical Androgens (HI, Florida Healthy Kids, MD, NJ, NY, PA, RI) Prior Authorizaton Form - Community Plan
Last Published 12.31.2019
-
Topical NSAIDs (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Topical Retinoid Products (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Trelegy Ellipta (FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorziation Form - Community Plan
Last Published 12.31.2019
-
Tremfya (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Triptans (FLCHIP, HI, MA, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tykerb (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Tymlos Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Uloric (AZ, HI, Florida Healthy Kids, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Vaginal Progesterone (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Valchlor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Vancocin (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Vancomycin (FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Vecamyl (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Vemlidy (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Venclexta (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Verzenio (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
VFend (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.27.2018
-
Vitrakvi (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Vizimpro (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Votrient (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Vyndaqel / Vyndamax (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Vytorin (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.25.2018
-
Xalkori (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xarelto (FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xeljanz / Xeljanz XR (FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xenazine (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xermelo (AZ, HI, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xifaxan (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xolair (AZ, HI, LA, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xopenex Respules (AZ, HI, MD, NJ, NY, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xospata (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xtandi (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xuriden (AZ, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Xyrem (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Yonsa (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Zejula (AZ, FLCHIP, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Zelboraf (AZ, Florida Healthy Kids, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Zetia (Rhode Island) Prior Authorization Form - Community Plan
Last Published 04.27.2018
-
Zolinza (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Zontivity (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Zydelig (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Zykadia (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Zytiga (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019
-
Zyvox (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.31.2019