Authorization Request Forms

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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)Open a PDF Drug Prior Authorization Request Forms
Aimovig, Ajovy, & EmgalityOpen a PDF Drug Prior Authorization Request Forms
Alpha 1 Anti-trypsin Therapy (AAT) - Aralast NP, Glassia, Prolastin-C, ZemairaOpen 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, Ziextenzo)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
Egrifta (Lypodysytrophy)Open a PDF Drug Prior Authorization Request Forms
EnteralOpen a PDF Drug Prior Authorization Request Forms
EntyvioOpen 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
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, Iedipasvir/sofosbuvir, Mavyret, Olysio, Pegasys, PEG-Intron, Ribavirin, sofosbuvir/velpatasvir, 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
Immune Checkpoint Inhibitors (Health Professional Administered) (Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Opdivo, Tecentriq, 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) - 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 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-5 Antagonists - (Cinqair & Fasenra) Rx & MedicalOpen a PDF Drug Prior Authorization Request Forms
Kalydeco (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 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
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, 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 Drug Prior Authorization Request Forms
Oncology Biosimilar Drug Products: (Health Professional Administered) - (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, 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 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 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
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 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
Synagis for Respiratory Syncytial Virus (RSV) ProphylaxisOpen a PDF Drug Prior Authorization Request Forms
Tepezza (teprotumumab-trbw)Open a PDF
TestosteroneOpen a PDF Drug Prior Authorization Request Forms
Tremfya (Healthcare Professional Administered) For Psoriasis or Psoriatic ArthritisOpen 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
Xolair (omalizumab)Open a PDF Drug Prior Authorization Request Forms
Zulresso (brexanolone injection)Open a PDF Drug Prior Authorization Request Forms
Showing 1– 85 of 85 Results
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