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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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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, Orlistat, Qsymia, Saxenda, Wegovy, XenicalOpen 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 Crohns Disease & Rheumatoid Arthritis (Self Administered)Open a PDF
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Drug Prior Authorization Request Forms
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Cimzia for 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, CAR-T Therapy Drugs, Ceprotin, Hydroxyprogesterone, Krystexxa, Lemtrada, Leqvio, NPlate, Ocrevus, Saphnelo, Spravato, Trogarzo, Tysabri, 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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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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Gilenya for Multiple SclerosisOpen 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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HAE (Hereditary Angioedema) - 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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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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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 (CPI) (Health Professional Administered) (Bavencio, Imfinzi, 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, 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
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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 (Self Admin)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 (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
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Drug Prior Authorization Request Forms
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Oncology Biosimilar Drug Products: (Health Professional Administered) - (Alymsys, 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, 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
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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 SQOpen 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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PsoriasisOpen 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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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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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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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 for Psoriasis or Psoriatic Arthritis (Health Professional Administration)Open 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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Stelera for Crohn's Disease & Ulcerative ColitisOpen 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) - Subcutaneous Injection for Management of AsthmaOpen a PDF
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Tremfya for Psoriasis or Psoriatic Arthritis (Healthcare Professional Administered)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, 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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Xolair (omalizumab)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)Open a PDF
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Drug Prior Authorization Request Forms
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