| 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 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, Qsymia, Saxenda, XenicalOpen 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 |
| Avastin (bevacizumab), Mvasi (bevacizumab-awwb) & Zirabev (bevacizumab-bvzr) For Cancer OnlyOpen 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 | |
| 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 |
| 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/Medical Benefit) - Aldurazyme (laronidase), Brineura (cerliponase alfa), Cerezyme (imiglucerase), Crysvita (burosumab-twza), Elaprase (idursulfase), Elelyso (taliglucerase alfa), Fabrazyme (agalisidase beta), Gamifant (emapalumab-lzsg), Kanuma (sebelipase alfa), Lumizyme (alglucosidase alfa), Mepsevii (vestronidase alfa-vjbk), Naglazyme (galsulfase), Onpattro (patisiran), 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) - Adagen (pegademase bovine), Carbaglu (carglumic acid), Cerdelga (eliglustat), Cholbam (cholic acid), Galafold (migalastat), Kuvan (sapropterin), 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 (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 |
| Medicaid Managed Care - Medical Specialty Drugs (Health Professional Administered) Standardized Authorization FormOpen a PDF | Medicaid Managed Care Use Only |
| Medicaid Managed Care for Pharmacy 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 |
| Nplate - (For ITP)Open 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 |
| Nucala & Fasenra (Self-Administration) (Nucala autoinjector, Nucala pre-filled syringes, Fasenra autoinjector, Fasenra PEN)Open a PDF | Drug Prior Authorization Request Forms |
| Nucala Autoinjector or Prefilled Syringe (Self Administration)Open a PDF | |
| Off-LabelOpen a PDF | Drug Prior Authorization Request Forms |
| 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 | Drug Prior Authorization Request Forms |
