Authorization Request Forms

or
Showing 1– 89 of 89 Results
Display Title Category
Actemra IV (Health Professional Administered) For Rheumatoid Arthritis & Systemic Juvenile Idiopathic ArthritisOpen a PDF Drug Prior Authorization Request Forms
Acthar HP (Repository corticotropin)Open a PDF Drug Prior Authorization Request Forms
Adakveo (Management of Sickle Cell Disease (SCD))Open a PDF Drug Prior Authorization Request Forms
Aimovig, Ajovy, & EmgalityOpen a PDF Drug Prior Authorization Request Forms
Alpha-1 Antitrypsin Deficiency (AAT) - (Aralast NP, Glassia, Prolastin-C, Zemaira)Open a PDF Drug Prior Authorization Request Forms
Anemia (Self Administered) - (Aranesp, Epogen, Procrit)Open a PDF Drug Prior Authorization Request Forms
Anorexiants (Weight Loss Medications-New Start & Re-certification) Contrave, Qsymia, Saxenda, Wegovy, XenicalOpen a PDF Drug Prior Authorization Request Forms
Blood Modifiers (Cosela, Fulphila, Granix, Neupogen, Nivestym, Releuko, Ziextenzo)Open a PDF Drug Prior Authorization Request Forms
Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) for Medicaid Managed Care, Essential Plan, and Child Health PlusOpen a PDF Drug Prior Authorization Request Forms
Cimzia & Humira Crohns Disease & Rheumatoid Arthritis (Self Administered)Open a PDF Drug Prior Authorization Request Forms
Cimzia for 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, CAR-T Therapy Drugs, Ceprotin, Hydroxyprogesterone, Krystexxa, Lemtrada, Leqvio, NPlate, Ocrevus, Saphnelo, Spravato, Trogarzo, Tysabri, 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
Dupixent (dupilumab)Open a PDF Drug Prior Authorization Request Forms
Egrifta (Lypodysytrophy)Open a PDF Drug Prior Authorization Request Forms
EnteralOpen a PDF Drug Prior Authorization Request Forms
Entyvio for Crohn’s Disease or Ulcerative ColitisOpen a PDF Drug Prior Authorization Request Forms
Evkeeza (evinacumab-dgnb)Open a PDF
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
Gilenya for Multiple SclerosisOpen a PDF Drug Prior Authorization Request Forms
Growth Hormone Therapy for Omnitrope®Open a PDF Drug Prior Authorization Request Forms
Hemlibra (emicizumab-kxwh)Open a PDF Drug Prior Authorization Request Forms
Hepatitis C - (Daklinza, Epclusa, Harvoni, Iedipasvir/sofosbuvir, Mavyret, Olysio, Pegasys, PEG-Intron, Ribavirin, sofosbuvir/velpatasvir, Sovaldi, Technivie, Viekira, Vosevi, Zepatier)Open 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) - Health Professional 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
Immune Checkpoint Inhibitors (CPI) (Health Professional Administered) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Opdualag, Tecentriq, and Yervoy)Open a PDF
ImmuneGlobulin: Intravenous (IVIG) & Subcutaneous (SCIG) - (Bivigam, Carimune, Flebogamma, Gammagard, Gamunex-C, Gammaked, Hizentra, HyQvia, Octagam, Privigen)Open a PDF Drug Prior Authorization Request Forms
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 Drug Prior Authorization Request Forms
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 Drug Prior Authorization Request Forms
Infertility - Cetrotide, chorionic gonadotropin (hCG), Endometrin, Follistim AQ, Ganirelix, Gonal-F, Leuprolide, Menopur, Novarel, Ovidrel, PregnylOpen a PDF Drug Prior Authorization Request Forms
Inflammatory Conditions (Self Admin)Open a PDF Drug Prior Authorization Request Forms
Interleukin Antagonists - (Cinqair & Fasenra) Rx & MedicalOpen a PDF Drug Prior Authorization Request Forms
Kalydeco for (Cystic Fibrosis)Open a PDF Drug Prior Authorization Request Forms
Korlym for Cushing's SyndromeOpen a PDF Drug Prior Authorization Request Forms
Krystexxa for GoutOpen a PDF Drug Prior Authorization Request Forms
Kuvan - (PKU)Open a PDF Drug Prior Authorization Request Forms
Lemtrada (alemtuzumab) for Multiple SclerosisOpen a PDF Drug Prior Authorization Request Forms
Leqvio® (inclisiran injection)Open 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 ITPOpen a PDF Drug Prior Authorization Request Forms
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 Drug Prior Authorization Request Forms
Nucala (mepolizumab) Rx or Medical BenefitOpen a PDF Drug Prior Authorization Request Forms
Off Label Use of FDA Approved drugsOpen a PDF Drug Prior Authorization Request Forms
Oncology (Self Administration) - (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, Zytiga)Open a PDF Drug Prior Authorization Request Forms
Oncology Biosimilar Drug Products: (Health Professional Administered) - (Alymsys, Avastin, Herceptin, Herceptin Hylecta, Herzuma, Ogivri, Ontruzant, Riabni, Rituxan, Rituxan Hycela)Open a PDF Drug Prior Authorization Request Forms
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 Drug Prior Authorization Request Forms
Onychomycosis - Jublia Solution, Kerydin Solution, Onmel TabletsOpen a PDF Drug Prior Authorization Request Forms
Opioid Prior Authorization Request Form for Drug and Morphine Milligram Equivalents ReviewsOpen a PDF Drug Prior Authorization Request Forms
Orencia SQOpen a PDF Drug Prior Authorization Request Forms
Orencia® (abatacept) Intravenous (IV) for RA, JIA, & PsAOpen a PDF Drug Prior Authorization Request Forms
Osteoporosis (Forteo, Teriparatide, & Tymlos)Open a PDF Drug Prior Authorization Request Forms
Osteoporosis for Evenity & ProliaOpen a PDF Drug Prior Authorization Request Forms
Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp)Open a PDF Drug Prior Authorization Request Forms
PCSK9 Inhibitors - Praluent, Repatha (For Medicaid Managed Care Only)Open a PDF Drug Prior Authorization Request Forms
Promacta for ITPOpen a PDF Drug Prior Authorization Request Forms
PsoriasisOpen a PDF Drug Prior Authorization Request Forms
Pulmonary Hypertension (Medical Benefit-Health Professional Administered) - (Epoprostenol, Flolan, Remodulin, Treprostinil, Veletri, Ventavis)Open a PDF Drug Prior Authorization Request Forms
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, Uptravi)Open a PDF Drug Prior Authorization Request Forms
Reblozyl (luspatercept-aamt) for Anemia in Adults with Beta Thalassemia OR Anemia in Adults with Myelodysplastic SyndromesOpen a PDF Drug Prior Authorization Request Forms
Remicade® (infliximab), Renflexis® (infliximab-abda), AvsolaTM (infliximab-axxq, Infliximab (unbranded))Open a PDF Drug Prior Authorization Request Forms
Request for Step Therapy Evaluation Prior Auth FormOpen a PDF Drug Step Therapy Request Forms
SabrilOpen a PDF Drug Prior Authorization Request Forms
Saphnelo (anifrolumab-fnia) IV for Systemic Lupus Erythematosus (SLE)Open a PDF Drug Prior Authorization Request Forms
Simponi Aria for Rheumatoid Arthritis (Health Professional Administered)Open a PDF Drug Prior Authorization Request Forms
Spravato (esketamine nasal spray)Open a PDF Drug Prior Authorization Request Forms
Stelara for Psoriasis or Psoriatic Arthritis (Health Professional Administration)Open a PDF Drug Prior Authorization Request Forms
Stelera (Self-Administration) - (For Psoriasis or Psoriatic Arthritis)Open a PDF Drug Prior Authorization Request Forms
Stelera for Crohn's Disease & Ulcerative Colitis (Health Professional Administered)Open a PDF Drug Prior Authorization Request Forms
Synagis for Respiratory Syncytial Virus (RSV) ProphylaxisOpen a PDF Drug Prior Authorization Request Forms
Tepezza (teprotumumab-trbw) for Medical BenefitOpen a PDF
TestosteroneOpen a PDF Drug Prior Authorization Request Forms
Tezspire™ (tezepelumab-ekko) - Subcutaneous Injection for Management of AsthmaOpen a PDF
Tremfya for Psoriasis or Psoriatic Arthritis (Healthcare Professional Administered)Open a PDF Drug Prior Authorization Request Forms
Univera Specialty Medications 10.15.2020.pdfOpen a PDF General Medications
Vabysmo® (faricimab-svoa)Open a PDF Drug Prior Authorization Request Forms
Viscosupplementation with Hyaluronic Acid for Osteoarthritis of the Knee (Durolane, Gel-One, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3)Open a PDF Drug Prior Authorization Request Forms
Vyepti (eptinezumab-jimr)Open a PDF Drug Prior Authorization Request Forms
Xolair (omalizumab)Open a PDF Drug Prior Authorization Request Forms
Zoladex (goserelin implant)Open a PDF Drug Prior Authorization Request Forms
Zulresso (brexanolone injection)Open a PDF Drug Prior Authorization Request Forms
Showing 1– 89 of 89 Results
IE Browser Modal