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Actimmune (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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ADHD/Anti-Narcolepsy: Non-Stimulants [Qelbree] (Washington) Prior Authorization Form - Community Plan
Last Published 03.31.2023
Qelbree,
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Afinitor (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Alecensa (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Alunbrig (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Androgen Biosynthesis Inhibitors [Abiraterone, Yonsa, Zytiga] (Washington) Prior Authorization Form - Community Plan
Last Published 08.01.2024
"Abiraterone, Yonsa, Zytiga",
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Androgenic Agents - Testosterone Replacement (Washington) Prior Authorization Form - Community Plan
Last Published 07.22.2021
Androderm, Androgel, testosterone, Methitest, methyltestosterone, Depo-testosterone, Fortesta, Striant, Testim, Vogelxo, Testopel, Xyosted, Aveed, Jatenzo, Natesto ,
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Anti-narcolepsy agents (Washington) Prior Authorization Form - Community Plan
Last Published 05.31.2024
"Armodafinil, Modafinil, Lumryz, Sunosi, Wakix, Xyrem, Xywav ",
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Antiasthmatic Monoclonal Antibodies, IL-5 Antagonists [Fasenra, Cinqair, Nucala] (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Antibiotics, Anti-Infective Agents, Oral (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
XIFAXAN,
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Antibiotics, Inhaled Aztreonam [Cayston] (Washington) Prior Authorization Form - Community Plan
Last Published 07.22.2021
CAYSTON,
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Antidepressants (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Antidepressants: Serotonin Modulators [Nefazodone, Trintellix, Viibryd] (Washington) Prior Authorization Form - Community Plan
Last Published 01.31.2022
"Nefazodone, Trintellix, Viibryd",
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Antidiabetics, Amlyin Analogs [SymlinPen®] (Washington) Prior Authorization Form - Community Plan
Last Published 05.09.2022
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Antidiabetics: GLP-1 Agonists (Washington) Prior Authorization Form - Community Plan
Last Published 01.31.2022
"Adlyxin, Bydureon Bcise, Ozempic, Rybelsus, Trulicity",
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Antihyperlipidemics [Icosapent Ethyl, Vascepa] (Washington) Prior Authorization Form - Community Plan
Last Published 01.22.2024
"Vascepa, icosapent ethyl ",
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Antihyperlipidemics PCSK9 Inhibitors (Washington) Prior Authorization Form - Community Plan
Last Published 01.22.2024
"Praluent, Repatha",
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Antihyperuricemic Agents (Washington) Prior Authorization Form - Community Plan
Last Published 07.22.2021
Gloperba, Uloric, febuxostat, Krystexxa,
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Antipsychotics (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Antivirals: HIV - Cabenuva (cabotegravir/rilpivirine) (Washington) Prior Authorization Form - Community Plan
Last Published 06.22.2022
"Cabenuva, cabotegravir-rilpivirine",
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Antivirals: HIV - Combinations (Washington) Prior Authorization Form - Community Plan
Last Published 01.09.2023
Dovato, Juluca, Temixys, Biktarvy, Symfi, Symfi Lo, efavirenz-lamivudine-tenofovir disoproxil fumarate, Symtuza, Cimduo, Triumeq,
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Antivirals: HIV - Descovy (emtricitabine / tenofovir alafenamide (Washington) Prior Authorization Form - Community Plan
Last Published 03.24.2023
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Antivirals: HIV - Edurant (rilpivirine) (Washington) Prior Authorization Form - Community Plan
Last Published 12.01.2021
Edurant,
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Asthma and COPD Agents: Monoclonal Antibodies - Anti-IgE Antibodies [Xolair] (Washington) Prior Authorization Form - Community Plan
Last Published 08.01.2024
Xolair,
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Atopic Dermatitis Agents, Topical Immunosuppressive (Washington) Prior Authorization Form - Community Plan
Last Published 07.22.2021
Elidel, pimecrolimus, Protopic, tacrolimus,
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Atopic Dermatitis Agents: Eucrisa (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Biltricide (Washington) Prior Authorization Form - Community Plan
Last Published 07.22.2021
Biltricide,
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Bone Density Regulators [Tymlos, Prolia, Forteo] (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Bosulif (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Cabometyx (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Caprelsa (Washington) Prior Authorization Form - Community Plan
Last Published 07.22.2021
Caprelsa,
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Chronic GI Motility Agents (Washington) Prior Authorization Form - Community Plan
Last Published 07.11.2022
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Compound Medications (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Corticosteroids [Emflaza] (Washington) Prior Authorization Form - Community Plan
Last Published 01.29.2024
Emflaza,
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Cotellic (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Cystic Fibrosis Agents, Oral (Washington) Prior Authorization Form - Community Plan
Last Published 07.22.2021
KALYDECO, ORKAMBI, SYMDEKO, TRIKAFTA ,
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Cytokine and CAM Antagonists (Washington) Prior Authorization Form - Community Plan
Last Published 07.22.2021
Orencia, Orencia Clickject, Humira, Kineret, Otezla, Olumiant, Siliq, Ilaris, Cimzia, Enbrel, Simponi, Simponi Aria, Tremfya, Remicade, Renflexis, Inflectra, Taltz, Arcalyst, Kevzara, Cosentyx, Ilumya, Actemra, Xeljanz, Xeljanz XR, Stelara, Entyvio, Avsola, Skyrizi, Rinvoq,
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Dermatologics: Acne Products (Isotretinoin) (Washington) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Absorica, isotretinoin, Absorica LD, Accutane, Amnesteem, Claravis, Myorisan, Zenatane ,
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Dupixent (Washington) Prior Authorization Form - Community Plan
Last Published 11.30.2023
Dupixent,
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Endocrine Metabolic Agents, Metabolic Modifiers (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Erivedge (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Erleada (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Exception to Rule (ETR) Request (Washington) Prior Authorization Form - Community Plan
Last Published 04.03.2023
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Farydak (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Fentanyl, Transmucosal Products (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Gilotrif (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Growth Hormones (Washington) Prior Authorization Form - Community Plan
Last Published 07.11.2022
Genotropin, Genotropin MiniQuick, Humatrope, Humatrope Combo Pak, Norditropin, Norditropi FlexPro, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive,
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Hematopoietic Agents- Erythropoiesis Stimulating Agents [Aranesp, Epogen, Procrit] (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Hematopoietic Agents- Granulocyte Colony Stimulating Factors [Neulasta, Neupogen, Zarxio] (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Hematopoietic Agents- Thrombopoiesis Stimulating Proteins [Doptelet, Promacta, Tavalisse] (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Ibrance (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Iclusig (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Idhifa (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Imbruvica (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Imidazotetrazines, Oral [Temodar, Temozolomide] (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Immune Modulators, Thalidomide Analogues (Washington) Prior Authorization Form - Community Plan
Last Published 09.30.2024
"Lenalidomide, Pomalyst, Revlimid, Thalomid",
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Inlyta (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Insulin Pen Needles and Syringes (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Intron A and Sylatron (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Iressa (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Jakafi (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Korlym (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Lenvima (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Lonsurf (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Lynparza (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Makena (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
,
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Medicaid Synagis Authorization Request Form - Community Plan
Last Published 04.01.2023
Synagis,
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Mekinist (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Migraine Agents: Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist [Prophylaxis] (Washington) Prior Authorization Form - Community Plan
Last Published 03.31.2023
"Aimovig, Ajovy, Emgality, Qulipta, Vyepti ",
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Movement Disorder Agents [Ingrezza] (Washington) Prior Authorization Form - Community Plan
Last Published 09.30.2024
Ingrezza,
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Multiple Sclerosis, Ocrevus (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Nerlynx (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Neuromuscular Agents - Lupus Agents (Washington) Prior Authorization Form - Community Plan
Last Published 05.31.2024
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Ninlaro (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Nityr (Washington) Prior Authorization Form - Community Plan
Last Published 07.29.2023
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Ophthalmic Immunomodulators [Xiidra] (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Opioid Attestation Form (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Orfadin (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Panretin (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Proton Pump Inhibitors (Washington) Prior Authorization Form - Community Plan
Last Published 03.01.2024
Dexilant, Nexium, esomeprazole, Prevacid, lansoprazole, Prilosec, omeprazole, Protonix, pantoprazole, Aciphex, rabeprazole, Zegerid, dexlansoprazole, omeprazole/sodium bicarbonate, Konvomep,
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Psychotherapeutic and Neurological Agents – MISC: Transthyretin Amyloidosis Agents (Washington) Prior Authorization Form - Community Plan
Last Published 07.29.2023
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Pulmonary Arterial Hypertension (Washington) Prior Authorization Form - Community Plan
Last Published 02.21.2022
Letairis, ambrisentan, Tracleer, bosentan, Opsumit, Revatio, sildenafil, Adcirca, tadalafil, Uptravi, Ventavis, Orenitram, Tyvaso, Adempas,
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Pulmonary Fibrosing Agents (Washington) Prior Authorization Form - Community Plan
Last Published 04.01.2023
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Respiratory Agents - MISC: Alpha-Proteinase Inhibitor, Human (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Rubraca (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Rydapt (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Sandostatin (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Second Opinion Network Medications (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Signifor (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Sleep Disorder Agents [Hetlioz] (Washington) Prior Authorization Form - Community Plan
Last Published 05.31.2024
Hetlioz,
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Sprycel (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Sutent (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Synribo (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Tafinlar (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Tagrisso (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Tarceva (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Tasigna (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Test Strips (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Tykerb (Washington) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Valchlor (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Verzenio (Washington) Prior Authorization Form - Community Plan
Last Published 07.29.2023
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Votrient (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Xalkori (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Zejula (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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Zelboraf (Washington) Prior Authorization Form - Community Plan
Last Published 07.29.2023
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Zydelig (Washington) Prior Authorization Form - Community Plan
Last Published 07.28.2023
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