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Zulresso (brexanolone injection) For Postpartum DepressionOpen a PDF
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Drug Prior Authorization Request Forms
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Zoladex (goserelin implant)Open a PDF
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Drug Prior Authorization Request Forms
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Xolair (omalizumab)Open a PDF
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Drug Prior Authorization Request Forms
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Vyepti (eptinezumab-jimr)Open a PDF
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Drug Prior Authorization Request Forms
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Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3)Open a PDF
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Drug Prior Authorization Request Forms
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Vabysmo® (faricimab-svoa)Open a PDF
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Drug Prior Authorization Request Forms
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Tremfya (Health Professional Administered) for Psoriasis or Psoriatic ArthritisOpen a PDF
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Drug Prior Authorization Request Forms
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Tezspire™ (tezepelumab-ekko) - Subcutaneous Injection for Management of AsthmaOpen a PDF
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TestosteroneOpen a PDF
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Drug Prior Authorization Request Forms
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Tepezza (teprotumumab-trbw) for Medical BenefitOpen a PDF
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Synagis (Respiratory Syncytial Virus (RSV) Prophylaxis)Open a PDF
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Drug Prior Authorization Request Forms
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Stelara for Crohn's Disease & Ulcerative Colitis - Health Professional AdministeredOpen a PDF
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Drug Prior Authorization Request Forms
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Stelara (Self-Administered) - (Psoriasis or Psoriatic Arthritis)Open a PDF
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Drug Prior Authorization Request Forms
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Stelara (Health Professional Administered) - (Psoriasis or Psoriatic Arthritis)Open a PDF
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Drug Prior Authorization Request Forms
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Spravato® (esketamine nasal spray)Open a PDF
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Drug Prior Authorization Request Forms
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Simponi Aria for Rheumatoid Arthritis (Office Administration)Open a PDF
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Drug Prior Authorization Request Forms
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Saphnelo (anifrolumab-fnia) IV For Systemic Lupus Erythematosus (SLE)Open a PDF
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Drug Prior Authorization Request Forms
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SabrilOpen a PDF
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Drug Prior Authorization Request Forms
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Request for Step Therapy Evaluation Prior Authorization FormOpen a PDF
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Drug Step Therapy Request Forms
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Remicade® (infliximab), Renflexis® (infliximab-abda), AvsolaTM (infliximab-axxq, Infliximab (unbranded))Open a PDF
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Drug Prior Authorization Request Forms
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Reblozyl (luspatercept-aamt) For Anemia in Adults with Beta Thalassemia or Anemia in Adults with Myelodysplastic SyndromesOpen a PDF
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Drug Prior Authorization Request Forms
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Pulmonary Hypertension (Pharmacy Benefit/Self Administered) - (Adcirca, Adempas, Alyq, Ambrisentan, Bosentan, Letairis, Macitentan, Opsumit, Orenitram, Revatio, Riociguat, Selexipag, Sildenafil, Tadalafil, Tracleer, Treprostinil, Treprostinil Inhalation, Tyvaso, UptraviOpen a PDF
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Drug Prior Authorization Request Forms
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Pulmonary Hypertension (Medical Benefit-Health Professional Administered) - (Epoprostenol, Flolan, Remodulin, Treprostinil, Veletri, Ventavis)Open a PDF
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Drug Prior Authorization Request Forms
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Psoriasis - (Cosentyx, Enbrel, Humira, Otezla)Open a PDF
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Drug Prior Authorization Request Forms
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Promacta for ITPOpen a PDF
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Drug Prior Authorization Request Forms
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PCSK9 Inhibitors - Praluent, Repatha (For Medicaid Managed Care Only)Open a PDF
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Drug Prior Authorization Request Forms
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Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp)Open a PDF
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Drug Prior Authorization Request Forms
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Osteoporosis for Evenity & ProliaOpen a PDF
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Drug Prior Authorization Request Forms
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Osteoporosis for (Forteo, Teriparatide, & Tymlos)Open a PDF
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Drug Prior Authorization Request Forms
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Orencia® (abatacept) Intravenous (IV) RA, JIA, & PsAOpen a PDF
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Drug Prior Authorization Request Forms
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Orencia® (abatacept) Intravenous (IV) for RA, JIA, & PsAOpen a PDF
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Drug Prior Authorization Request Forms
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Opioid Prior Authorization Request Form for Drug and Morphine Milligram Equivalents ReviewsOpen a PDF
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Drug Prior Authorization Request Forms
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Onychomycosis - Jublia Solution, Kerydin Solution, Onmel TabletsOpen a PDF
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Drug Prior Authorization Request Forms
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Oncology CRPA - Medical (Healthcare Professional Administered) (Abecma, Adcetris, Aliqopa, Arzerra, Asparlas, Beleodaq, Belrapzo, Besponsa, Blenrep, Blincyto, Breyanzi, Camcevi, Cyramza, Danyelza, Darzalex., Darzalex Faspro, Elzonris, Empliciti, Enhertu, Erwinaze, Folotyn, Fyarro, Gazyva, Istodax, romidepsin, Jelmyto, Kadcyla, Kimmtrak, Kymriah, Kyprolis, Lartruvo, Lumoxiti, Margenza, Marqibo, Monjuvi, Mylotarg, Oncaspar, Onivyde, Padcev, Phesgo, Polivy, Portrazza, Poteligeo, Provenge, Rybrevant, Rylaze, Sarclisa, Synribo, Tecartus, Tivdak, Torisel, Trodelvy, Vyxeos, Yescarta, Yondelis, Zaltrap, Zepzelca, Zynlonta)Open a PDF
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Drug Prior Authorization Request Forms
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Oncology CRPA (Self Administered) - Afinitor, Afinitor Disperz, Alecensa, Alunbrig, Ayvakit, Balversa, Besremi, Braftovi, Brukinsa, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Daurismo, Erivedge, Erleada, Exkivity, Farydak, Fotivda, Gavreto, Gilotrif, Hemady, Ibrance, Iclusig, Idhifa, Imbruvica, Inlyta, Inqovi, Inrebic, Jakafi, Kisqali, Kisqali Femara Co-Pack, Koselugo, Lenvima, Lonsurf, Lorbrena, Lumakras, Lynparza, Mekinist, Mektovi, Nerlynx, Ninlaro, Nubeqa, Odomzo, Onureg, Orgovyx, Pemazyre, Piqray, Pomalyst, Purixan, Qinlock, Retevmo, Rezurock, Rozlytrek, Rubraca, Rydapt, Scemblix, Soltamox, Stivarga, Tabrecta, Tafinlar, Tagrisso, Talzenna, Targretin Capsules, Targretin Gel, Tazverik, Tepmetko, Tibsovo, Truseltiq, Tukysa, Turalio, Ukoniq, Valchlor, Venclexta, Verzenio, Vitrakvi, Vizimpro, Votrient, Welireg, Xalkori, Xermelo, Xospata, Xpovio, Xtandi, Yonsa, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, ZytigaOpen a PDF
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Drug Prior Authorization Request Forms
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Oncology Biosimilar Drug Products: (Health Professional Administered) - (Alymsys, Avastin, Herceptin, Herceptin Hylecta, Herzuma, Ogivri, Ontruzant, Riabni, Rituxan, Rituxan Hycela))Open a PDF
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Drug Prior Authorization Request Forms
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Off-Label - (Use of FDA Approved Drugs)Open a PDF
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Drug Prior Authorization Request Forms
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Nucala (mepolizumab) - Rx and MedicalOpen a PDF
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Drug Prior Authorization Request Forms
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NSAIDs - (Duexis, fenoprofen tablets, Flector, Licart, diclofenac patches, indomethacin capsules, indomethacin suppositories, ketoprofen capsules, Naprelan, naproxen ER, naproxen suspension, Pennsaid, Qmiiz, Relafen DS, Sprix, ketorolac/tromethamine nasal spray, Tivorbex, Vimovo, Vivlodex, meloxicam capsules, Zipsor, Zorvolex and diclofenac 35 mg capsules)Open a PDF
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Drug Prior Authorization Request Forms
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Nplate for ITPOpen a PDF
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Drug Prior Authorization Request Forms
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Medication Duplication Safety EditOpen a PDF
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Drug Prior Authorization Request Forms
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Medicare D Opioid Prior Authorization Form - Request for Drug & Morphine Milligram Equivalents ReviewOpen a PDF
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Drug Exception Forms
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Medicare D Lidocaine Patch & Flector Patch - Request for Drug EvaluationOpen a PDF
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Drug Exception Forms
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Medicare D Hospice - Request for Drug EvaluationOpen a PDF
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Drug Exception Forms
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Medicare D End Stage Renal Disease - Request for Drug EvaluationOpen a PDF
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Drug Exception Forms
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Medicaid Managed Care-Medical Specialty Drugs (Health Professional Administered) Standard Authorization FormOpen a PDF
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Medicaid Managed Care Use Only
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Medicaid Managed Care for Pharmacy Drugs-Standard Prior Authorization FormOpen a PDF
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Medicaid Managed Care Use Only
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Leqvio® (inclisiran injection)Open a PDF
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Drug Prior Authorization Request Forms
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Lemtrada (alemtuzumab) For Multiple SclerosisOpen a PDF
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Drug Prior Authorization Request Forms
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Kuvan - (PKU)Open a PDF
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Drug Prior Authorization Request Forms
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Krystexxa (For Gout)Open a PDF
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Drug Prior Authorization Request Forms
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Korlym for Cushing's SyndromeOpen a PDF
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Kalydeco (Cystic Fibrosis)Open a PDF
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Drug Prior Authorization Request Forms
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Interleukin Antagonists - (Cinqair & Fasenra) Rx and MedicalOpen a PDF
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Drug Prior Authorization Request Forms
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Inflammatory Conditions - Cimzia, Cosentyx, Enbrel, Humira, Kineret, SimponiOpen a PDF
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Drug Prior Authorization Request Forms
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Infertility - (Cetrotide, chorionic gonadotropin (hCG), Endometrin, Follistim AQ, Ganirelix, Gonal-F, Leuprolide, Menopur, Novarel, Ovidrel, Pregnyl)Open a PDF
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Drug Prior Authorization Request Forms
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Inborn Errors of Metabolism & Rare Genetic Diseases (Self Administration/Pharmacy Benefit) - Carbaglu (carglumic acid), Cerdelga (eliglustat), Cholbam (cholic acid), Dojolvi, Galafold (migalastat), Nitisinone, 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
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Drug Prior Authorization Request Forms
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Inborn Errors of Metabolism & Rare Genetic Diseases (Health Professional Administration/Medical Benefit) - Aldurazyme, Brineura (cerliponase alfa), Cerezyme (imiglucerase), Crysvita (burosumab-twza), Elaprase (idursulfase), Elelyso (taliglucerase alfa), Exondys, Fabrazyme (agalisidase beta), Givlaari, Kanuma (sebelipase alfa), Lumizyme (alglucosidase alfa), Mepsevii (vestronidase alfa-vjbk), Naglazyme (galsulfase), Nexviazyme, Nulibry, Onpattro (patisiran), Oxlumo, Scenesse (afamelanotide), Spinraza, Vimizim (elosulfase alfa), VPRIV (velaglucerase alfa)Open a PDF
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Drug Prior Authorization Request Forms
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ImmuneGlobulin: Intravenous (IVIG) & Subcutaneous (SCIG) - (Bivigam, Carimune, Flebogamma, Gammagard, Gamunex-C, Gammaked, Hizentra, HyQvia, Octagam, Privigen)Open a PDF
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Drug Prior Authorization Request Forms
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Immune Checkpoint Inhibitors (Health Professional Administered) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Opdualag, Tecentriq, and Yervoy)Open a PDF
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Ilumya For Psoriasis (Health Professional Administered)Open a PDF
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Drug Prior Authorization Request Forms
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Hepatitis C - Daklinza, Epclusa, Harvoni, Iedipasvir/sofosbuvir, Mavyret, Olysio, Pegasys, PEG-Intron, Ribavirin, sofosbuvir/velpatasvir, Sovaldi, Technivie, Viekira, Vosevi, ZepatierOpen a PDF
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Drug Prior Authorization Request Forms
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Hemlibra (emicizumab-kxwh)Open a PDF
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Drug Prior Authorization Request Forms
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HAE (Hereditary Angioedema) - Self Administered - (Berinert, Cinryze, Firazyr, Haegarda, Icatibant, Ruconest, Takhzyro)Open a PDF
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Drug Prior Authorization Request Forms
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HAE (Hereditary Angioedema) - Health Professional Administered - (Berinert, Cinryze, Kalbitor, Ruconest)Open a PDF
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Drug Prior Authorization Request Forms
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Growth Hormone Therapy for (Omnitrope)Open a PDF
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Drug Prior Authorization Request Forms
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Gilenya for Multiple SclerosisOpen a PDF
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Drug Prior Authorization Request Forms
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Generic Advantage Program / MAC Penalty Exception Request FormOpen a PDF
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Drug Exception Forms
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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
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Drug Exception Forms
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Excellus Specialty Medications 10.15.2020.pdfOpen a PDF
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General Medications
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Evkeeza (evinacumab-dgnb)Open a PDF
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Entyvio for Crohn’s Disease or Ulcerative ColitisOpen a PDF
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Drug Prior Authorization Request Forms
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EnteralOpen a PDF
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Drug Prior Authorization Request Forms
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Egrifta (Lypodysytrophy)Open a PDF
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Drug Prior Authorization Request Forms
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Dupixent (dupilumab)Open a PDF
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Drug Prior Authorization Request Forms
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Contraceptive Exception Request-NYS Standard FormOpen a PDF
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Compounded Drug ProductsOpen a PDF
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Drug Prior Authorization Request Forms
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Clinical Review Prior Authorization (Rx)Open a PDF
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Drug Prior Authorization Request Forms
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Clinical Review Prior Authorization (Medical) For Healthcare Professional Administration Only - (Cablivi, CAR-T Therapy Drugs, Ceprotin, Hydroxyprogesterone, Krystexxa, Lemtrada, Leqvio, NPlate, Ocrevus, Saphnelo, Spravato, Trogarzo, Tysabri, or any other Medical agent)Open a PDF
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Drug Prior Authorization Request Forms
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Cimzia - Crohn's Disease & Rheumatoid Arthritis (Health Professional Administered)Open a PDF
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Drug Prior Authorization Request Forms
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Cimzia & Humira Crohns Disease & Rheumatoid Arthritis (Self Administered)Open a PDF
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Drug Prior Authorization Request Forms
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Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) for Medicaid Managed Care, Essential Plan, and HARPOpen a PDF
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Drug Prior Authorization Request Forms
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Blood Modifiers (Cosela, Fulphila, Granix, Neupogen, Nivestym, Releuko, Ziextenzo)Open a PDF
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Drug Prior Authorization Request Forms
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Anorexiants (Weight Loss Medications-New Start & Re-certification) Contrave, Qsymia, Saxenda, Wegovy, XenicalOpen a PDF
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Drug Prior Authorization Request Forms
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Anemia (Self-Administered) - (Aranasp, Epogen, Procrit)Open a PDF
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Drug Prior Authorization Request Forms
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Alpha-1 Antitrypsin Deficiency (AAT) - (Aralast NP, Glassia, Prolastin-C, Zemaira)Open a PDF
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Drug Prior Authorization Request Forms
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Aimovig, Ajovy, & EmgalityOpen a PDF
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Drug Prior Authorization Request Forms
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Adakveo (Management of Sickle Cell Disease)Open a PDF
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Drug Prior Authorization Request Forms
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Acthar HP (Repository corticotropin)Open a PDF
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Drug Prior Authorization Request Forms
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Actemra IV (Health Professional Administered) For Rheumatoid Arthritis & Systemic Juvenile Idiopathic Arthritis)Open a PDF
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Drug Prior Authorization Request Forms
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