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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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Adakveo (Management of Sickle Cell Disease (SCD))Open a PDF
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Drug Prior Authorization Request Forms
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Aduhelm for Medicaid Managed CareOpen a PDF
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Aimovig, Ajovy, & EmgalityOpen a PDF
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Drug Prior Authorization Request Forms
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Alpha-1 Antitrypsin Deficiency (AAT) - (Aralast NP, Glassia, Prolastin-C, Zemaira)Open a PDF
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Drug Prior Authorization Request Forms
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Blood Modifiers (Cosela, Fulphila, Fylnetra, Granix, Neulasta, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Udenyca, Ziextenzo)Open a PDF
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Drug Prior Authorization Request Forms
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Botulinum Toxin (Botox, Dysport, Myobloc, Xeomin) for Medicaid Managed Care, Essential Plan, and Child Health PlusOpen a PDF
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Drug Prior Authorization Request Forms
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Cimzia & Humira (Self Administered) for Crohn's Disease & Rheumatoid ArthritisOpen a PDF
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Drug Prior Authorization Request Forms
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Cimzia (Health Professional Administered) for Crohn's Disease & Rheumatoid ArthritisOpen 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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Clinical Review Prior Authorization - Medical Benefit (Healthcare Professional Administration Only) – (17 alpha-hydroxyprogesterone, Cablivi, Ceprotin, Hydroxyprogesterone, Krystexxa, Makena, Ocrevus, Sunlenca, Trogarzo, Tysabri, or any other medical agent)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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Entyvio for Crohn’s Disease or Ulcerative ColitisOpen 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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GnRH Analogs - Fensolvi®, Triptodur®, Supprelin LA®Open a PDF
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Drug Prior Authorization Request Forms
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Growth Hormone Therapy for Omnitrope®Open a PDF
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Drug Prior Authorization Request Forms
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Hemlibra (emicizumab-kxwh)Open 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, Zepatier)Open 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) - Health Professional 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, Sajazir, 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 Inhibitor (CPI) (Health Professional Administered) - (Bavencio, Imfinzi, Imjudo, Jemperli, Keytruda, Libtayo, Opdivo, Opdualag, Tecentriq, and 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) - Aldurazyme, Amvuttra, 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), Xenpozyme)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, Cetrorelix Acetate, chorionic gonadotropin (hCG), Endometrin, Follistim AQ, Fyremadel, 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 - Pharmacy Benefit or Medical; Benefit - (Amjevita, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Simponi)Open a PDF
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Drug Prior Authorization Request Forms
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Interleukin Antagonists - (Cinqair & Fasenra) Rx & MedicalOpen a PDF
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Drug Prior Authorization Request Forms
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Kalydeco for (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) Standard Authorization FormOpen a PDF
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Medicaid Managed Care Use Only
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Medicaid Managed Care-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 ITPOpen 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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Omnipod Kits and Pods for Pharmacy BenefitOpen a PDF
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Oncology (CRPA) Medical (Health Professional Administered) - (Abecma, Abraxane (paclitaxel protein bound particles), Adcetris (brentuximab vedotin), Aliqopa (copanlisib), Arzerra (ofatumumab), Asparlas (calaspargase pegol-mknl), Beleodaq (belinostat), Belrapzo (bendamustine HCL), Bendeka (bendamustine HCL)*, Besponsa (inotuzumab ozogamicin), Blenrep (belantamab mafodotin-blmf), Blincyto (blinatumomab), Breyanzi, Camcevi (leuprolide mesylate), Carvykti, Cyramza (ramucirumab), Danyelza (naxitamab-gqgk), Darzalex (daratumumab), Darzalex Faspro (daratumumab and hyaluronidase-fihj), Elitek (rasburicase), Elzonris (tragraxofusp-erzs), Empliciti (elotuzumab), Enhertu (fam-trastuzumab deruxtecan-nxki), Erwinaze (asparaginase), Folotyn (pralatrexate), Fyarro (sirolimus protein-bound particles), Gazyva (obinutuzumab), Istodax (romidepsin), Jelmyto (mitomycin gel), Kadcyla (ado-trastuzumab emtansine), Kimmtrak (tebentafusp), Kymriah, Kyprolis (carfilzomib), Lartruvo (olaratumab injection), leuprolide Acetate Depot, Lumoxiti (moxetumomab pasudotox-tdfk), Lunsumio (mosunetuzumab-axgb), Margenza (margetuximab-cmkb), Marqibo (vincristine sulfate liposome injection), Monjuvi (tafasitamab-cxix), Mylotarg (gemtuzumab ozogamicin), Oncaspar (pegaspargase), Onivyde (irinotecan liposome injection), Padcev (enfortumab vedotin-ejfv), Pedmark (sodium thiosulfate), Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf), Polivy (polatuzumab vedotin-piiq), Portrazza (necitumumab), Poteligeo (mogamulizumab-kpkc), Provenge (sipuleucel-T), Rybrevant (amivantamab-vmjw), Rylaze (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sarclisa (isatuximab-irfc), Synribo (omacetaxine mepesuccinate), Tecvayli (teclistamab), Tecartus, Tivdak (tisotumab vedotin-tftv), Torisel (temsirolimus), Treanda (bendamustine HCL), Trodelvy (sacituzumab govitecan-hziy), Vivimusta (bendamustine HCL), Vyxeos, (Daunorubicin/Cytarabine), Yescarta, Yondelis (trabectedin), Zaltrap (ziv-aflibercept), Zepzelca (lurbinectedin), Zynlonta (loncastuximab tesirine-lpyl)Open a PDF
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Drug Prior Authorization Request Forms
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Oncology (CRPA) Rx (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, Jaypirca, 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
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Drug Prior Authorization Request Forms
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Oncology Biosimilar Drug Policy - (Avastin (bevacizumab) and Alymsys (bevacizumab-maly), Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Ogivri (trastuzumab-dkst), Ontruzant (trastuzumab-dttb), and Herzuma (trastuzumab-pkrb), Rituxan (rituximab), Rituxan Hycela (rituximab hyaluronidase), Riabni (rituximab-arrx) and Vegzelma (bevacizumab-adcd) (Medical))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 (abatacept) Subcutaneous Administration for RA, JIA, & PsAOpen a PDF
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Drug Prior Authorization Request Forms
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Orencia® (abatacept) Intravenous (IV) for RA, JIA, & PsAOpen 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, Repatha (For Medicaid Managed Care Only)Open a PDF
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Drug Prior Authorization Request Forms
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Promacta for ITPOpen a PDF
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Drug Prior Authorization Request Forms
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Psoriasis - (Amjevita, Cosentyx, Enbrel, Humira, Otezla)Open a PDF
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Drug Prior Authorization Request Forms
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Pulmonary Hypertension (Medical Benefit-Health Professional Administered) - (Epoprostenol, Flolan, Remodulin, Treprostinil, Veletri, Ventavis)Open a PDF
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Drug Prior Authorization Request Forms
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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
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Drug Prior Authorization Request Forms
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Rare Diseases (CRPA) Medical (Health Professional Administered) - Actimmune (Interferon gamma-1B), Aldurazyme (laronidase), Enjaymo (sutimlimab-jome), Enspryng (satralizumab-mwge injection), Gamifant (emapalumab-lzsg), Ilaris (canakinumab), Lanreotide Acetate Injection, Luxturna (voretigene neparvovec-rzyl, Radicava (edaravone), Rethymic (allogeneic processed thymus tissue-agdc), Revcovi (elapegademase-lvlr), Ryplazim (plasminogen, human-tvm), Scenesse (afamelanotide), Signifor LAR (pasireotide), Soliris (eculizumab), Ultomiris (ravulizumab-cwvz injection), Uplizna (inebilizumab-cdon), Vyvgart (efgartigimod alfa-fcab))Open a PDF
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Drug Prior Authorization Request Forms
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Rare Diseases (CRPA) Rx (Self-Administration) - (Actimmune (Interferon gamma-1B), Arcalyst (rilonacept), Bylvay (odevixibat), Camzyos (mavacamten capsules), Cuprimine and generic penicillamine capsules, Empaveli (pegcetacoplan), Enspryng (satralizumab-mwge injection), Exservan and Tiglutik (riluzole oral film and oral suspension), Firdapse (amifampridine), Hyftor 0.2% gel (sirolimus topical gel), Increlex (mecasermin), Recombinant, rh-IGF-1, Isturisa (osilodrostat tablets), Juxtapid (lomitapide capsules), Keveyis (dichlorphenamide), Lanreotide Acetate Injection, Livmarli (maralixibat), Myalept (metreleptin), Mycapssa (octreotide acetate), Procysbi (cysteamine capsules and packets), Pyrukynd (mitapivat tablets), Radicava (edaravone), Radicava (edaravone), Recorlev (levoketoconazole), Relyvrio (sodium phenylbutyrate and taurursodiol), Revcovi (elapegademase-lvlr), Ruzurgi (amifampridine), Ryplazim (plasminogen, human-tvm), Sandostatin LAR, Signifor SC (pasireotide solution), Somavert (pegvisomant), Syprine, Clovique, and generic trientine capsules, Tarpeyo (budesonide delayed release capsules), Tavneos (avacopan), Thiola, Thiola EC and generic tiopronin, Vijoice (alpelisib), Voxzogo (vosoritide), Zokinvy (lonafarnib), Ztalmy (ganaxolone))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), Infliximab (unbranded))Open a PDF
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Drug Prior Authorization Request Forms
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Repository Corticotropin Injection (Acthar HP and Purified Cortrophin gel)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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Sandostatin LAR (Rx or Medical Benefit)Open a PDF
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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 Aria for Rheumatoid Arthritis (Health Professional Administered)Open a PDF
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Drug Prior Authorization Request Forms
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Skyrizi (risankizumab-rzaa) Self-AdministrationOpen a PDF
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Drug Prior Authorization Request Forms
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Spevigo® (spesolimab-sbzo) InjectionOpen a PDF
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Spravato (esketamine nasal spray)Open a PDF
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Drug Prior Authorization Request Forms
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Stelara (Self-Administration) - (For Psoriasis or Psoriatic Arthritis)Open a PDF
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Drug Prior Authorization Request Forms
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Stelara for Crohn's Disease & Ulcerative ColitisOpen a PDF
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Drug Prior Authorization Request Forms
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Stelara for Psoriasis or Psoriatic Arthritis (Health Professional Administration)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) for Medical BenefitOpen a PDF
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TestosteroneOpen a PDF
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Drug Prior Authorization Request Forms
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Tezspire™ (tezepelumab-ekko) - Management of Asthma Rx and MedicalOpen a PDF
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Drug Prior Authorization Request Forms
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Tremfya (Health Professional Administered) for Psoriasis or Psoriatic ArthritisOpen a PDF
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Drug Prior Authorization Request Forms
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Tremfya (Self Administration) for Psoriasis or Psoriatic ArthritisOpen a PDF
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Drug Prior Authorization Request Forms
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Tzield™ (teplizumab-mzwv)Open 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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Vabysmo® (faricimab-svoa)Open a PDF
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Drug Prior Authorization Request Forms
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Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, 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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Vyepti (eptinezumab-jimr)Open a PDF
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Drug Prior Authorization Request Forms
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Vyvgart (efgartigimod alfa-fcab) (Health Professional Administered)Open a PDF
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Drug Prior Authorization Request Forms
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Weight Loss Medications (New Start & Re-certification) Contrave, Orlistat, Qsymia, Saxenda, Wegovy, XenicalOpen a PDF
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Drug Prior Authorization Request Forms
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Xolair (omalizumab) (Health Professional Administered OR Self - Administration) (Rx & Medical Benefit)Open a PDF
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Drug Prior Authorization Request Forms
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Zoladex (goserelin implant)Open a PDF
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Drug Prior Authorization Request Forms
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Zulresso (brexanolone injection) for Postpartum DepressionOpen a PDF
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Drug Prior Authorization Request Forms
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Zynteglo (betibeglogene autotemcel) Gene TherapyOpen a PDF
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Drug Prior Authorization Request Forms
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