| Actemra IV (Health Professional Administered)Open a PDF | Drug Prior Authorization Request Forms |
| ActharOpen a PDF | Drug Prior Authorization Request Forms |
| AdcetrisOpen a PDF | Drug Prior Authorization Request Forms |
| AliqopaOpen a PDF | Drug Prior Authorization Request Forms |
| Alpha 1 Anti-trypsin Therapy (AAT) - Prolastin-C, Aralast NP, Zemaira, GlassiaOpen a PDF | Drug Prior Authorization Request Forms |
| Anemia (Self Administered) - (Epogen, Procrit, Aranesp)Open a PDF | Drug Prior Authorization Request Forms |
| Anorexiants (Weight Loss Medications-New Start & Re-certification) Contrave, Belviq, Belviq XR, Qsymia, Saxenda, XenicalOpen a PDF | Drug Prior Authorization Request Forms |
| Anorexiants (Weight Loss Medications-New Start & Re-certification) Contrave, Belviq, Belviq XR, Qsymia, Saxenda, XenicalOpen a PDF | Drug Prior Authorization Request Forms |
| Avastin (bevacizumab), Mvasi (bevacizumab-awwb) & Zirabev (bevacizumab-bvzr) For Cancer OnlyOpen a PDF | Drug Prior Authorization Request Forms |
| Benlysta IVOpen a PDF | Drug Prior Authorization Request Forms |
| Benlysta SCOpen 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 - (Benlysta IV, Ceprotin, Hydroxyprogesterone, Ilaris, Krystexxa, Lemtrada, Luxturna, NPlate, Nulojix, Ocrevus, Radicava, Signifor LAR, Soliris, Sylvant, Trogarzo, Ultomiris)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 |
| EgriftaOpen a PDF | Drug Prior Authorization Request Forms |
| EnteralOpen a PDF | Drug Prior Authorization Request Forms |
| EntyvioOpen a PDF | Drug Prior Authorization Request Forms |
| Forteo, TymlosOpen 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 |
| HalavenOpen 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 |
| Hepatitis C - Daklinza, Epclusa, Harvoni, Olysio, Pegasys, PEG-Intron, Ribavirin, Sovaldi, Technivie, Viekira, Vosevi, ZepatierOpen a PDF | Drug Prior Authorization Request Forms |
| Hereditary Angioedema (HAE) - Provider Administered - (Berinert, Cinryze, Kalbitor, Ruconest)Open a PDF | Drug Prior Authorization Request Forms |
| Hereditary Angioedema (HAE) - Self Administered - (Berinert, Cinryze, Firazyr, Haegarda, Icatibant, Ruconest, Takhzyro)Open a PDF | Drug Prior Authorization Request Forms |
| ILumya - (For Psoriasis (Health Professional Administered))Open a PDF | Drug Prior Authorization Request Forms |
| ImmuneGlobulin: Intravenous (IVIG) and Subcutaneous (SCIG) - Carimune, Flebogamma, Gammagard, Gamunex, Gammaked, Hizentra, HyQvia, Octagan, Privigen, BivigamOpen a PDF | Drug Prior Authorization Request Forms |
| Inborn Errors of Metabolism & Rare Genetic Diseases (Health Professional Administration) - Adagen (pegademase bovine, Rx), Aldurazyme (laronidase, Medical),, Brineura (cerliponase alfa, Medical), Cerezyme (imiglucerase,Medical), Cholbam (cholic acid, Rx), Crysvita (burosumab-twza, Medical), Elaprase (idursulfase, Medical), Elelyso (taliglucerase alfa, Medical), Fabrazyme (agalisidase beta, Medical), Galafold (migalastat, Rx), Gamifant (emapalumab-lzsg, Medical), Kanuma (sebelipase alfa, Medical), Kuvan (sapropterin, Rx), Lumizyme (alglucosidase alfa, Medical), Mepsevii (vestronidase alfa-vjbk, Medical), Naglazyme (galsulfase, Medical), Nityr (nitisinone, Rx), Onpattro (patisiran, Medical), Palynziq (pegvaliase-pqpz, Rx), Ravicti (glycerol phenylbutyrate, Rx), Revcovi (elapegademase-lvlr, Rx), Strensiq (asfotase alfa, Rx), Tegsedi (inotersen, Rx), Vimizim (elosulfase alfa Medical), VPRIV (velaglucerase alfa Medical))Open a PDF | Drug Prior Authorization Request Forms |
| Inborn Errors of Metabolism & Rare Genetic Diseases (Self Administration) - Adagen (pegademase bovine, Rx), Aldurazyme (laronidase, Medical),, Brineura (cerliponase alfa, Medical), Carbaglu (carglumic acid, Rx), Cerdelga (eliglustat, Rx), Cerezyme (imiglucerase,Medical), Cholbam (cholic acid, Rx), Crysvita (burosumab-twza, Medical), Elaprase (idursulfase, Medical), Elelyso (taliglucerase alfa, Medical), Fabrazyme (agalisidase beta, Medical), Galafold (migalastat, Rx), Gamifant (emapalumab-lzsg, Medical), Kanuma (sebelipase alfa, Medical), Kuvan (sapropterin, Rx), Lumizyme (alglucosidase alfa, Medical), Mepsevii (vestronidase alfa-vjbk, Medical), Naglazyme (galsulfase, Medical), Nityr (nitisinone, Rx), Onpattro (patisiran, Medical), Orfadin (nitisinone, Rx), Palynziq (pegvaliase-pqpz, Rx), Ravicti (glycerol phenylbutyrate, Rx), Revcovi (elapegademase-lvlr, Rx), Strensiq (asfotase alfa, Rx), Sucraid (sacrosidase, Rx), Tegsedi (inotersen, Rx), Vimizim (elosulfase alfa Medical), VPRIV (velaglucerase alfa Medical), Xuriden (uridine triacetate, Rx), Zavesca (miglustat Rx)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 (Self Admin)Open a PDF | Drug Prior Authorization Request Forms |
| Interleukin-5 Antagonists - (Cinqair, Fasenra, Nucala)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 |
| MarqiboOpen a PDF | Drug Prior Authorization Request Forms |
| Medicaid Managed Care for Medical Specialty Drugs-Health Professional Administered Standardized Authorization FormOpen a PDF | Medicaid Managed Care Use Only |
| Medicaid Managed Care Prescription Drugs Standard Prior 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 |
| MozobilOpen a PDF | Drug Prior Authorization Request Forms |
| Nplate - (For ITP)Open a PDF | Drug Prior Authorization Request Forms |
