|
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
|
|
Blood Modifiers (Fulphila, Granix, Neupogen, Nivestym, Neulasta, Ziextenzo (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
|
|
|
Dupixent (dupilumab)Open 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
|
|
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
|
|
HemlibraOpen 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), Exondys, Fabrazyme (agalisidase beta), Gamifant (emapalumab-lzsg), Givlaari, Kanuma (sebelipase alfa), Lumizyme (alglucosidase alfa), Mepsevii (vestronidase alfa-vjbk), Naglazyme (galsulfase), 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 - (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, 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
|
|
NucalaOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
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
|
|
Oncology Biosimilar Drug Products: (Health Professional Administered - bevacizumab, trastuzumab, and rituximab)Open a PDF
|
Drug Prior Authorization Request Forms
|
|
Oncology CRPA - Medical Healthcare Professional AdministeredOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
Onychomycosis - Jublia, Kerydin, OnmelOpen 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 IVOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
Orencia SQOpen 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, RepathaOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
PromactaOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
PsoriasisOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
Pulmonary Arterial Hypertension (Health Professional Administered) - (Epoprostenol, Treprostinil, Flolan, Remodulin, Treprostinil, Veletri, Ventavis)Open a PDF
|
Drug Prior Authorization Request Forms
|
|
Pulmonary Arterial Hypertension (Self Administration) - (Adcirca, Adempas, Ambrisentan, Bosentan, Letairis, Opsumit, Orenitram, Revatio, Sildenafil, Tadalafil, Tracleer, Tyvaso, Uptravi)Open a PDF
|
Drug Prior Authorization Request Forms
|
|
Remicade® (infliximab), Renflexis® (infliximab-abda), AvsolaTM (infliximab-axxq)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
|
|
Simponi AriaOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
SpravatoOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
Stelara (Health Professional Administration) - (For Psoriasis or Psoriatic Arthritis)Open a PDF
|
Drug Prior Authorization Request Forms
|
|
Stelera (Crohn's Disease) & Ulcerative ColitisOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
Stelera (Self-Administration) - (For Psoriasis or Psoriatic Arthritis)Open a PDF
|
Drug Prior Authorization Request Forms
|
|
SynagisOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
TestosteroneOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
TremfyaOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
Univera Specialty Medications 10.15.2020.pdfOpen a PDF
|
General Medications
|
|
Viscosupplementation with Hyaluronic Acid - (Durolane, Gel-One, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3)Open a PDF
|
Drug Prior Authorization Request Forms
|
|
VyeptiOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
Xgeva (Health Professional Administration) For Prevention of (SRE) Skeletal Related EventsOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
XolairOpen a PDF
|
Drug Prior Authorization Request Forms
|
|
Zulresso (brexanolone injection)Open a PDF
|
Drug Prior Authorization Request Forms
|
