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Actemra IV (Health Professional Administered)Open a PDF
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Drug Prior Authorization Request Forms
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ActharOpen 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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Alpha 1 Anti-trypsin Therapy (AAT) - Prolastin-C, Aralast NP, Zemaira, GlassiaOpen a PDF
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Drug Prior Authorization Request Forms
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Anemia (Self Administered) - (Epogen, Procrit, Aranesp)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, XenicalOpen a PDF
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Drug Prior Authorization Request Forms
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Blood Modifiers (Fulphila, Granix, Neupogen, Nivestym, Neulasta, Ziextenzo (Medicaid/Child Health Plus Members Only))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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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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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
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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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Compounded Drug ProductsOpen 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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Dupixent (dupilumab)Open a PDF
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Drug Prior Authorization Request Forms
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EgriftaOpen 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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EntyvioOpen a PDF
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Drug Prior Authorization Request 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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Generic Advantage Program/ MAC Penalty Exception Request FormOpen a PDF
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Drug Exception Forms
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GilenyaOpen a PDF
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Drug Prior Authorization Request Forms
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Growth HormoneOpen a PDF
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Drug Prior Authorization Request Forms
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HemlibraOpen a PDF
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Drug Prior Authorization Request Forms
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Hepatitis C - Daklinza, Epclusa, Harvoni, Olysio, Pegasys, PEG-Intron, Ribavirin, Sovaldi, Technivie, Viekira, Vosevi, ZepatierOpen a PDF
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Drug Prior Authorization Request Forms
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Hepatitis C - Daklinza, Epclusa, Harvoni, Olysio, Pegasys, PEG-Intron, Ribavirin, Sovaldi, Technivie, Viekira, Vosevi, ZepatierOpen a PDF
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Drug Prior Authorization Request Forms
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Hereditary Angioedema (HAE) - Provider Administered - (Berinert, Cinryze, Kalbitor, Ruconest)Open a PDF
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Drug Prior Authorization Request Forms
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Hereditary Angioedema (HAE) - 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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ILumya - (For Psoriasis (Health Professional Administered))Open a PDF
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Drug Prior Authorization Request Forms
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ImmuneGlobulin: Intravenous (IVIG) and Subcutaneous (SCIG) - Carimune, Flebogamma, Gammagard, Gamunex, Gammaked, Hizentra, HyQvia, Octagan, Privigen, BivigamOpen 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 (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
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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), 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
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Drug Prior Authorization Request Forms
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Infertility - (Bravelle, Cetrotide, corionic gonadotropin, Fertinex, Ganirelix, Gonal-F, Lupron, Luveris, Menopur, Novarel, Ovidrel, Pregnyl)Open a PDF
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Drug Prior Authorization Request Forms
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Inflammatory Conditions (Self Admin)Open a PDF
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Drug Prior Authorization Request Forms
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Interleukin-5 Antagonists - (Cinqair, Fasenra, Nucala)Open a PDF
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Drug Prior Authorization Request Forms
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KalydecoOpen a PDF
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Drug Prior Authorization Request Forms
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KorlymOpen a PDF
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Drug Prior Authorization Request Forms
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KrystexxaOpen 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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LemtradaOpen a PDF
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Drug Prior Authorization Request Forms
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Medicaid Managed Care - Medical Specialty Drugs (Health Professional Administered) Standardized 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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Medicare D End Stage Renal Disease - 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 Lidocaine Patch & Flector Patch - Request for Drug EvaluationOpen a PDF
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Drug Exception Forms
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Nplate - (For ITP)Open a PDF
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Drug Prior Authorization Request Forms
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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
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Drug Prior Authorization Request Forms
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NucalaOpen a PDF
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Drug Prior Authorization Request Forms
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Off-LabelOpen a PDF
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Drug Prior Authorization Request Forms
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Oncology (Self Administration) - (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, Zytiga)Open a PDF
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Drug Prior Authorization Request Forms
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Oncology Biosimilar Drug Products: (Health Professional Administered - bevacizumab, trastuzumab, and rituximab)Open a PDF
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Drug Prior Authorization Request Forms
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Oncology CRPA - Medical Healthcare Professional AdministeredOpen a PDF
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Drug Prior Authorization Request Forms
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Onychomycosis - Jublia, Kerydin, OnmelOpen 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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Orencia IVOpen a PDF
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Drug Prior Authorization Request Forms
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Orencia SQOpen a PDF
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Drug Prior Authorization Request Forms
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Osteoporosis (Forteo, Teriparatide, & Tymlos)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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Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp)Open a PDF
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Drug Prior Authorization Request Forms
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PCSK9 Inhibitors - Praluent, RepathaOpen a PDF
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Drug Prior Authorization Request Forms
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PromactaOpen a PDF
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Drug Prior Authorization Request Forms
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PsoriasisOpen a PDF
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Drug Prior Authorization Request Forms
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Pulmonary Arterial Hypertension (Health Professional Administered) - (Epoprostenol, Treprostinil, Flolan, Remodulin, Treprostinil, Veletri, Ventavis)Open a PDF
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Drug Prior Authorization Request Forms
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Pulmonary Arterial Hypertension (Self Administration) - (Adcirca, Adempas, Ambrisentan, Bosentan, Letairis, Opsumit, Orenitram, Revatio, Sildenafil, Tadalafil, Tracleer, Tyvaso, Uptravi)Open a PDF
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Drug Prior Authorization Request Forms
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Remicade® (infliximab), Renflexis® (infliximab-abda), AvsolaTM (infliximab-axxq)Open a PDF
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Drug Prior Authorization Request Forms
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Request for Step Therapy Evaluation Prior Auth FormOpen a PDF
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Drug Step Therapy Request Forms
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SabrilOpen a PDF
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Drug Prior Authorization Request Forms
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Simponi AriaOpen a PDF
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Drug Prior Authorization Request Forms
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SpravatoOpen a PDF
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Drug Prior Authorization Request Forms
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Stelara (Health Professional Administration) - (For Psoriasis or Psoriatic Arthritis)Open a PDF
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Drug Prior Authorization Request Forms
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Stelera (Crohn's Disease) & Ulcerative ColitisOpen a PDF
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Drug Prior Authorization Request Forms
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Stelera (Self-Administration) - (For Psoriasis or Psoriatic Arthritis)Open a PDF
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Drug Prior Authorization Request Forms
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SynagisOpen a PDF
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Drug Prior Authorization Request Forms
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TestosteroneOpen a PDF
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Drug Prior Authorization Request Forms
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TremfyaOpen a PDF
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Drug Prior Authorization Request Forms
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Univera Specialty Medications 10.15.2020.pdfOpen a PDF
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General Medications
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Viscosupplementation with Hyaluronic Acid - (Durolane, Gel-One, 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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VyeptiOpen a PDF
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Drug Prior Authorization Request Forms
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Xgeva (Health Professional Administration) For Prevention of (SRE) Skeletal Related EventsOpen a PDF
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Drug Prior Authorization Request Forms
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XolairOpen a PDF
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Drug Prior Authorization Request Forms
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Zulresso (brexanolone injection)Open a PDF
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Drug Prior Authorization Request Forms
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