Authorization Request Forms

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Showing 1– 78 of 78 Results
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Actemra IV (Health Professional Administered)Open a PDF Drug Prior Authorization Request Forms
ActharOpen a PDF Drug Prior Authorization Request Forms
Aimovig, Ajovy, & EmgalityOpen a PDF Drug Prior Authorization Request Forms
Alpha-1 Antitrypsin Deficiency (AAT) - (Aralast NP, Glassia, Prolastin-C, Zemaira)Open a PDF Drug Prior Authorization Request Forms
Anemia (Self-Administered) - (Aranasp, Epogen, Procrit)Open a PDF Drug Prior Authorization Request Forms
Anorexiants (Weight Loss Medications-New Start & Re-certification) Contrave, Qsymia, Saxenda, XenicalOpen a PDF Drug Prior Authorization Request Forms
Blood Modifiers (Fulphila, Granix, Neupogen, Nivestym, Neulasta, (Medicaid/Child Health Plus Members Only))Open a PDF Drug Prior Authorization Request Forms
Cimzia & HUmira Crohns Disease & Rheumatoid Arthritis (Self Administered)Open a PDF Drug Prior Authorization Request Forms
Cimzia Crohn's Disease & Rheumatoid Arthritis (Health Professional Administered)Open a PDF Drug Prior Authorization Request Forms
Clinical Review Prior Authorization (Medical) For Healthcare Professional Administration Only - (Cablivi, Ceprotin, Hydroxyprogesterone, Ilaris, Krystexxa, Lemtrada, Luxturna, NPlate, Ocrevus, Radicava, Signifor LAR, Soliris, Spravato, Sylvant, Tepezza, Trogarzo, Ultomiris or any other Medical agent)Open a PDF Drug Prior Authorization Request Forms
Clinical Review Prior Authorization (Rx)Open a PDF Drug Prior Authorization Request Forms
Compounded Drug ProductsOpen a PDF Drug Prior Authorization Request Forms
Contraceptive Exception Request-NYS Standard FormOpen a PDF
Dupixent (dupilumab)Open a PDF Drug Prior Authorization Request Forms
EgriftaOpen a PDF Drug Prior Authorization Request Forms
EnteralOpen a PDF Drug Prior Authorization Request Forms
EntyvioOpen a PDF Drug Prior Authorization Request Forms
General Exception Request Form (Self Administered Drugs) - (used for requests that do not have a specific form below, or may be used to request an exception)Open a PDF Drug Exception Forms
Generic Advantage Program / MAC Penalty Exception Request FormOpen a PDF Drug Exception Forms
GilenyaOpen a PDF Drug Prior Authorization Request Forms
Growth HormoneOpen a PDF Drug Prior Authorization Request Forms
HAE (Hereditary Angioedema) - Provider Administered - (Berinert, Cinryze, Kalbitor, Ruconest)Open a PDF Drug Prior Authorization Request Forms
HAE (Hereditary Angioedema) - Self Administered - (Berinert, Cinryze, Firazyr, Haegarda, Icatibant, Ruconest, Takhzyro)Open a PDF Drug Prior Authorization Request Forms
Hepatitis C - Daklinza, Epclusa, Harvoni, Olysio, Pegasys, PEG-Intron, Ribavirin, Sovaldi, Technivie, Viekira, Vosevi, ZepatierOpen a PDF Drug Prior Authorization Request Forms
IlumyaOpen a PDF Drug Prior Authorization Request Forms
Inborn Errors of Metabolism & Rare Genetic Diseases (Health Professional Administration/Medical Benefit) - Aldurazyme (laronidase), Brineura (cerliponase alfa), Cerezyme (imiglucerase), Crysvita (burosumab-twza), Elaprase (idursulfase), Elelyso (taliglucerase alfa), Exondys, Fabrazyme (agalisidase beta), Gamifant (emapalumab-lzsg), Kanuma (sebelipase alfa), Lumizyme (alglucosidase alfa), Mepsevii (vestronidase alfa-vjbk), Naglazyme (galsulfase), Onpattro (patisiran), Scenesse (afamelanotide), Vimizim (elosulfase alfa), VPRIV (velaglucerase alfa)Open a PDF Drug Prior Authorization Request Forms
Inborn Errors of Metabolism & Rare Genetic Diseases (Self Administration/Pharmacy Benefit) - Carbaglu (carglumic acid), Cerdelga (eliglustat), Cholbam (cholic acid), Galafold (migalastat), Nityr tablet (nitisinone), Orfadin capsule / suspension (nitisinone), Palynziq (pegvaliase-pqpz), Ravicti (glycerol phenylbutyrate), Revcovi (elapegademase-lvlr), Strensiq (asfotase alfa), Sucraid (sacrosidase), Tegsedi (inotersen), Vyndamax (tafamidis), Vyndaqel (tafamidis meglumine), Xuriden (uridine triacetate), Zavesca (miglustat)Open a PDF Drug Prior Authorization Request Forms
Infertility - (Bravelle, Cetrotide, corionic gonadotropin, Fertinex, Ganirelix, Gonal-F, Lupron, Luveris, Menopur, Novarel, Ovidrel, Pregnyl)Open a PDF Drug Prior Authorization Request Forms
Inflammatory Conditions - Cimzia, Cosentyx, Enbrel, Humira, Kineret, SimponiOpen a PDF Drug Prior Authorization Request Forms
Interleukin-5 Antagonists - (Cinqair, Fasenra, Nucala)Open a PDF Drug Prior Authorization Request Forms
IVIG & SCIG - (Bivigam, Carimune, Flebogamma, Gammagard, Gamunex, Gammaked, Hizentra, HyQvia, Octagan, Privigen)Open a PDF Drug Prior Authorization Request Forms
KalydecoOpen a PDF Drug Prior Authorization Request Forms
KorlymOpen a PDF Drug Prior Authorization Request Forms
KrystexxaOpen a PDF Drug Prior Authorization Request Forms
Kuvan - (PKU)Open a PDF Drug Prior Authorization Request Forms
LemtradaOpen a PDF Drug Prior Authorization Request Forms
Medicaid Managed Care for Pharmacy Drugs-Standard Prior Authorization FormOpen a PDF Medicaid Managed Care Use Only
Medicaid Managed Care-Medical Specialty Drugs (Health Professional Administered) Standard Authorization FormOpen a PDF Medicaid Managed Care Use Only
Medicare D End Stage Renal Disease - Request for Drug EvaluationOpen a PDF Drug Exception Forms
Medicare D Hospice - Request for Drug EvaluationOpen a PDF Drug Exception Forms
Medicare D Lidocaine Patch & Flector Patch - Request for Drug EvaluationOpen a PDF Drug Exception Forms
Medicare D Opioid Prior Authorization Form - Request for Drug & Morphine Milligram Equivalents ReviewOpen a PDF Drug Exception Forms
Medication Duplication Safety EditOpen a PDF Drug Prior Authorization Request Forms
NplateOpen a PDF Drug Prior Authorization Request Forms
NSAIDs - Duexis (ibuprofen/famotidine), Fenoprofen tablets, Flector (diclofenac patch), Pennsaid (diclofenac 2% solution), Sprix (ketorolac/tromethamine nasal spray), Tivorbex (indomethacin), Vimovo (naproxen/esomeprazole), Vivlodex (meloxicam), Zipsor (diclofenac), Zorvolex (diclofenac)Open a PDF Drug Prior Authorization Request Forms
Off-Label - (FDA Approved Drugs)Open a PDF Drug Prior Authorization Request Forms
Oncology (Self Administered) - Afinitor, Bosulif, Caprelsa, Cometriq, Erivedge, Gilotrif, Hycamtin, Iclusig, Imbruvica, Inlyta, Jakafi, Mekinist, Nexavar, Pomalyst, Revlimid, Signifor, Sprycel, Stivarga, Sutent, Sylatron Tafinlar, Tarceva, Tasigna, Tykerb, Valchlor, Votrient, Xalkori, Xtandi, Zelboraf, Zolinza, ZytigaOpen a PDF Drug Prior Authorization Request Forms
Oncology Biosimilar Drug Products: (Health Professional Administered - bevacizumab, trastuzumab, and rituximab)Open a PDF Drug Prior Authorization Request Forms
Oncology CRPA - Medical Healthcare Professional Administered (Adcetria, Aliqopa, Arzerra, Asparlas, Bavencio, Beleodaq, Besponsa, Blincyto, Cyramza, Darzalex, Elzonris, Empliciti, Enhertu, Erwinaze, Folotyn, Gazyva, Herceptin Hylecta, Imfinzi, Istodax & Romidepsin, Kadcyla, Keytruda, Kymriah, Kyprolis, Lartruvo, Libtayo, Lumoxiti, Marqibo, Mylotarg, Oncaspar, Onivyde, Opdivo, Padcev, Polivy, Portrazza, Poteligeo, Provenge, Synribo, Tecentriq, Torisel, Vyxeos, Xgeva, Yervoy, Yescarta, Yondelis, Zaltrap)Open a PDF Drug Prior Authorization Request Forms
Onychomycosis - Jublia Solution, Kerydin Solution, Onmel TabletsOpen a PDF Drug Prior Authorization Request Forms
Opioid Prior Authorization Request Form for Drug and Morphine Milligram Equivalents ReviewsOpen a PDF Drug Prior Authorization Request Forms
Orencia IVOpen a PDF Drug Prior Authorization Request Forms
Orencia SQOpen a PDF Drug Prior Authorization Request Forms
Osteoporosis (Forteo, Teriparatide, & Tymlos)Open a PDF Drug Prior Authorization Request Forms
Osteoporosis for Evenity & ProliaOpen a PDF Drug Prior Authorization Request Forms
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp)Open a PDF Drug Prior Authorization Request Forms
PCSK9 Inhibitors - Praluent, RepathaOpen a PDF Drug Prior Authorization Request Forms
PromactaOpen a PDF Drug Prior Authorization Request Forms
Psoriasis - (Cosentyx, Enbrel, Humira, Otezla)Open a PDF Drug Prior Authorization Request Forms
Pulmonary Arterial Hypertension (Health Professional Administered) - (Epoprostenol, Flolan, Remodulin, Treprostinil, Veletri, Ventavis)Open a PDF Drug Prior Authorization Request Forms
Pulmonary Arterial Hypertension (Self-Administered) - (Adcirca, Adempas, Ambrisentan, Bosentan, Letairis, Opsumit, Orenit)ram, Revatio, Sildenafil, Tadalafil, Tracleer, Tyvaso, UptraviOpen a PDF Drug Prior Authorization Request Forms
Remicade (infliximab), Inflectra (infliximab-dyyb), Renflexis (infliximab-abda) - Remicade (infliximab), Inflectra (infliximab-dyyb), Renflexis (infliximab-abda))Open a PDF Drug Prior Authorization Request Forms
Request for Step Therapy Evaluation Prior Authorization FormOpen a PDF Drug Step Therapy Request Forms
SabrilOpen a PDF Drug Prior Authorization Request Forms
Simponi AriaOpen a PDF Drug Prior Authorization Request Forms
Specialty Rx Medication List (Self-Administered Drugs)Open a PDF General Medications
SpravatoOpen a PDF Drug Prior Authorization Request Forms
Stelara (Health Professional Administered) - (Psoriasis or Psoriatic Arthritis)Open a PDF Drug Prior Authorization Request Forms
Stelara (Self-Administered) - (Psoriasis or Psoriatic Arthritis)Open a PDF Drug Prior Authorization Request Forms
Stelara for Crohn's Disease & Ulcerative ColitisOpen a PDF Drug Prior Authorization Request Forms
SynagisOpen a PDF Drug Prior Authorization Request Forms
TestosteroneOpen a PDF Drug Prior Authorization Request Forms
TremfyaOpen a PDF Drug Prior Authorization Request Forms
Viscosupplementation with Hyaluronic Acid - (Gel-One, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Synojoynt, Triluron, TriVisc, Visco-3)Open a PDF Drug Prior Authorization Request Forms
VyeptiOpen a PDF Drug Prior Authorization Request Forms
Xgeva (Health Professional Administration) For Prevention of (SRE) Skeletal Related EventsOpen a PDF Drug Prior Authorization Request Forms
XolairOpen a PDF Drug Prior Authorization Request Forms
Zulresso (brexanolone injection) For Postpartum DepressionOpen a PDF Drug Prior Authorization Request Forms
Showing 1– 78 of 78 Results