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Actemra IV (Health Professional Administered) For Rheumatoid Arthritis & Systemic Juvenile Idiopathic ArthritisOpen 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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Adakveo (Management of Sickle Cell Disease)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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Alpha 1 Anti-trypsin Therapy (AAT) - Aralast NP, Glassia, Prolastin-C, ZemairaOpen a PDF
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Drug Prior Authorization Request Forms
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Anemia (Self Administered) - (Aranesp, Epogen, Procrit)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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Blood Modifiers (Cosela, Fulphila, Granix, Neupogen, Nivestym, Ziextenzo)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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Egrifta (Lypodysytrophy)Open 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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Evkeeza (evinacumab-dgnb)Open a PDF
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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, 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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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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Immune Checkpoint Inhibitors (Health Professional Administered) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, Yervoy)Open a PDF
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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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Inborn Errors of Metabolism & Rare Genetic Diseases (Health Professional Administration/Medical Benefit) - Brineura (cerliponase alfa), Cerezyme (imiglucerase), Crysvita (burosumab-twza), Elaprase (idursulfase), Elelyso (taliglucerase alfa), Exondys, Fabrazyme (agalisidase beta), Gamifant (emapalumab-lzsg), 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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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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Infertility - Cetrotide, chorionic gonadotropin (hCG), Endometrin, Follistim AQ, Ganirelix, Gonal-F, Leuprolide, Menopur, Novarel, Ovidrel, PregnylOpen 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) Rx & MedicalOpen a PDF
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Drug Prior Authorization Request Forms
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Kalydeco (Cystic Fibrosis)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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Drug Prior Authorization Request Forms
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Krystexxa for GoutOpen 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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Lemtrada (alemtuzumab) For Multiple SclerosisOpen a PDF
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Drug Prior Authorization Request Forms
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Leqvio® (inclisiran injection)Open 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, 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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Nucala (Mepolizumab) Rx or Medical BenefitOpen a PDF
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Drug Prior Authorization Request Forms
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Off Label Use of FDA Approved drugsOpen a PDF
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Drug Prior Authorization Request Forms
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Oncology (Self Administration) - (Afinitor, Alecensa, Alunbrig, Bosulif, Braftovi, Cabometyx, Calquence, Caprelsa, Cometriq, Copiktra, Cotellic, Daurismo, Erivedge, Erleada, Farydak, Gilotrif, Hycamtin, Ibrance, Iclusig, Imbruvica, Inlyta, Iressa, Jakafi, Kisqali, Lenvima, Lonsurf, Lorbrena, Lynparza, Mekinist, Mektovi, Mozobil, Nerlynx, Nexavar, Ninlaro, Odomzo, Pomalyst, Purixan, Revlimid, Rubraca, Rydapt, Soltamox, Sprycel, Stivarga, Sutent, Sylatron Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin,Tasigna, Tibsovo, Tykerb, Valchlor, Venclexta, Verzenio, Vitrakvi, Vizimpro, Votrient, Xalkori, Xermelo, Xospata, Xtandi, Yonsa, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga)Open a PDF
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Drug Prior Authorization Request Forms
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Oncology Biosimilar Drug Products: (Health Professional Administered) - (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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Oncology CRPA - Medical (Healthcare Professional Administered) (Abecma, Adcetris, Aliqopa, Arzerra, Asparlas, Beleodaq, Belrapzo, Besponsa, Blenrep, Blincyto, Breyanzi, Cyramza, Danyelza, Darzalex., Darzalex Faspro, Elzonris, Empliciti, Enhertu, Erbitux, Erwinaze, Folotyn, Gazyva, Istodax & Romidepsin, Jelmyto, Kadcyla, Kymriah, Kyprolis, Lartruvo, Lumoxiti, Margenza, Marqibo, Monjuvi, Mylotarg, Oncaspar, Onivyde, Padcev, Pepaxto, Phesgo, Polivy, Portrazza, Poteligeo, Provenge, Rybrevant, Rylaze, Sarclisa, Synribo, Tecartus, Torisel, Trodelvy, Vyxeos, Yescarta, Yondelis, Zaltrap, Zepzelca, Zynlonta)Open 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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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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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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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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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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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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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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Synagis for Respiratory Syncytial Virus (RSV) ProphylaxisOpen a PDF
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Drug Prior Authorization Request Forms
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Tepezza (teprotumumab-trbw)Open a PDF
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TestosteroneOpen a PDF
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Drug Prior Authorization Request Forms
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Tremfya (Healthcare Professional Administered) For Psoriasis or Psoriatic ArthritisOpen 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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Xolair (omalizumab)Open 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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