Prior Authorization
2024 Prior Authorization Forms
Click any drug name below to view the corresponding prior authorization fax form.
Drugs are listed in alphabetical order. To jump to a specific section, click the letter below that corresponds with the first letter for the drug you are inquiring about:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
A
Acitretin 2024 PA Fax 1459-A V1 01-01-24
Actimmune 2024 PA Fax 562-A V1 01-01-24
Adalimumab 2024 PA Fax 107-A V3 01-01-24
Adempas 2024 PA Fax 1048-A V1 01-01-24
Afinitor 2024 PA Fax 415-A V1 01-01-24
Aimovig 2024 PA Fax 3193-A V1 01-01-24
Akeega 2024 PA Fax 6136-A V1 01-01-24
Albendazole 2024 PA Fax 5812-A V1 01-01-24
Aldurazyme 2024 PA Fax 573-A V1 01-01-24
Alecensa 2024 PA Fax 1322-A V1 01-01-24
Alpha-1 Proteinase Inhibitors 2024 PA Fax 11-A V1 01-01-24
Alunbrig 2024 PA Fax 1816-A V2 01-01-24
Ambrisentan 2024 PA Fax 640-A V1 01-01-24
Amphetamines 2024 PA Fax 1383-A V1 01-01-24
Ampyra 2024 PA Fax 477-A V1 01-01-24
Ancobon 2024 PA Fax 4603-A V1 01-01-24
Antiemetics 2024 PA Fax BD-16 V1 01-01-24
Arcalyst 2024 PA Fax 597-A V1 01-01-24
Austedo 2024 PA Fax 1748-A V2 01-01-24
Ayvakit 2024 PA Fax 3495-A V1 01-01-24
B
Bafiertam 2024 PA Fax 3884-A V1 01-01-24
Balversa 2024 PA Fax 2966-A V1 01-01-24
Banzel 2024 PA Fax 1386-A V1 01-01-24
Benlysta 2024 PA Fax 862-A V2 01-01-24
Besremi 2024 PA Fax 5062-A V1 01-01-24
Bosulif 2024 PA Fax 806-A V1 01-01-24
Braftovi 2024 PA Fax 2615-A V2 01-01-24
Briviact 2024 PA Fax 4558-A V3 01-01-24
Bronchitol 2024 PA Fax 4340-A V1 01-01-24
Brukinsa 2024 PA Fax 3414-A V3 01-01-24
Budesonide 2024 PA Fax 4498-A V1 01-01-24
Buprenorphine SL 2024 PA Fax 1391-A V1 01-01-24
Bydureon 2024 PA Fax 5567-A V2 01-01-2
Byetta 2024 PA Fax 5568-A V3 01-01-24
C
Cabometyx 2024 PA Fax 1367-A V1 01-01-24
Calquence 2024 PA Fax 2398-A V4 01-01-24
Caplyta 2024 PA Fax 4531-A V2 01-01-24
Caprelsa 2024 PA Fax 801-A V1 01-01-24
Carbaglu 2024 PA Fax 840-A V1 01-01-24
Cayston 2024 PA Fax 480-A V1 01-01-24
Cerdelga 2024 PA Fax 1188-A V1 01-01-24
Cerezyme 2024 PA Fax 1497-A V1 01-01-24
Chantix 2024 PA Fax 1393-A V1 01-01-24
Clobazam 2024 PA Fax 1443-A V1 01-01-24
Clomipramine 2024 PA Fax 2484-A V1 01-01-24
Clozapine ODT 2024 PA Fax 1403-A V1 01-01-24
Cometriq 2024 PA Fax 916-A V1 01-01-24
Copiktra 2024 PA Fax 2755-A V1 01-01-24
Cotellic 2024 PA Fax 1307-A V2 01-01-24
Cystagon 2024 PA Fax 803-A V1 01-01-24
Cysteamine opth 2024 PA Fax 926-A V1 01-01-24
D
Daurismo 2024 PA Fax 2794-A V1 01-01-24
Deferasirox 2024 PA Fax 553-A V1 01-01-24
Demser 2024 PA Fax 2531-A V1 01-01-24
Desvenlafaxine ER 2024 PA Fax 2485-A V1 01-01-24
Dexmethylphenidate 2024 PA Fax 4336-A V1 01-01-24
DHE Nasal 2024 PA Fax 2895-A V1 01-01-24
Diacomit 2024 PA Fax 2779-A V2 01-01-24
Diazepam PA Plus 2024 PA Fax 1473-B V1 01-01-24
Disposable Insulin Pumps 2024 PA Fax 3573-A V1 01-01-24
Doptelet 2024 PA Fax 2586-A V1 01-01-24
Dupixent 2024 PA Fax 1691-A V6 01-01-24
E
Eligard 2024 PA Fax 5263-A V1 01-01-24
Emend Varubi 2024 PA Fax BD-3 V1 01-01-24
Emsam 2024 PA Fax 1401-A V1 01-01-24
Enbrel 2024 PA Fax 80-A V1 01-01-24
Endari 2024 PA Fax 2211-A V1 01-01-24
Epclusa 2024 PA Fax 1508-A V2 01-01-24
Epidiolex 2024 PA Fax 2608-A V1 01-01-24
Epoetin 2024 PA Fax 81-A V2 01-01-24
Eprontia 2024 PA Fax 5286-A V2 01-01-24
Ergotamine 2024 PA Fax 4607-A V1 01-01-24
Erivedge 2024 PA Fax 762-A V1 01-01-24
Erleada 2024 PA Fax 2499-A V1 01-01-24
Esbriet 2024 PA Fax 1217-A V1 01-01-24
Exkivity 2024 PA Fax 4967-A V1 01-01-24
F
Fabrazyme 2024 PA Fax 576-A V1 01-01-24
Fanapt 2024 PA Fax 4533-A V2 01-01-24
Fasenra 2024 PA Fax 2414-A V2 01-01-24
Fentanyl Patch 2024 PA Fax 1398-A V1 01-01-24
Fetzima 2024 PA Fax 1404-A V1 01-01-24
Fintepla 2024 PA Fax 3983-A V1 01-01-24
Firmagon 2024 PA Fax 3873-A V1 01-01-24
Fotivda 2024 PA Fax 4620-A V1 01-01-24
Fycompa 2024 PA Fax 4557-A V2 01-01-24
G
Gattex 2024 PA Fax 938-A V1 01-01-24
Gavreto 2024 PA Fax 4207-A V1 01-01-24
Gilenya 2024 PA Fax 620-A V1 01-01-24
Gilotrif 2024 PA Fax 1011-A V1 01-01-24
Glatiramer 2024 PA Fax 544-A V1 01-01-24
Gleevec 2024 PA Fax 99-A V2 01-01-24
Gralise 2024 PA Fax 2535-A V1 01-01-24
Growth Hormone 2024 PA Fax 101-A V1 01-01-24
H
Harvoni 2024 PA Fax 1209-A V2 01-01-24
Hepatitis B 2024 PA Fax BD-5 V1 01-01-24
Herceptin Hylecta BDC 2024 PA Fax 2945-A BD-13 V1 01-01-24
Hetlioz 2024 PA Fax 1125-A V1 01-01-24
HRM Anticonvulsants 2024 PA Fax 1410-B V1 01-01-24
HRM Antiparkinson 2024 PA Fax 1416-B V1 01-01-24
HRM Cyproheptadine 2024 PA Fax 3513-B V1 01-01-24
HRM Dipyridamole 2024 PA Fax 3525-B V1 01-01-24
HRM Guanfacine ER 2024 PA Fax 3520-B V1 01-01-24
HRM Guanfacine IR 2024 PA Fax 3519-B V1 01-01-24
HRM Hydroxyzine Inj 2024 PA Fax 1415-B V1 01-01-24
HRM Hydroxyzine Oral 2024 PA Fax 1414-B V1 01-01-24
HRM Hypnotics 2024 PA Fax 1421-B V1 01-01-24
HRM Muscle Relaxants PA Plus 2024 PA Fax 1420-B V1 01-01-24
HRM Promethazine 2024 PA Fax 1413-B V1 01-01-24
HRM Scopolamine 2024 PA Fax 3510-B V1 01-01-24
I
Ibrance 2024 PA Fax 1236-A V2 01-01-24
Icatibant 2024 PA Fax 809-A V1 01-01-24
Iclusig 2024 PA Fax 920-A V2 01-01-24
Idhifa 2024 PA Fax 2239-A V1 01-01-24
Imbruvica 2024 PA Fax 1050-A V5 01-01-24
Inbrija 2024 PA Fax 2861-A V1 01-01-24
Increlex 2024 PA Fax 551-A V1 01-01-24
Infliximab 2024 PA Fax 187-A V1 01-01-24
Infusion 2024 PA Fax BD-20 V2 01-01-24
Injectables 2024 PA Fax BD-13 V1 01-01-24
Inlyta 2024 PA Fax 747-A V1 01-01-24
Inqovi 2024 PA Fax 4008-A V1 01-01-24
Inrebic 2024 PA Fax 3162-A V1 01-01-24
Interferon 2024 PA Fax 543-A V1 01-01-24
Iressa 2024 PA Fax 1282-A V1 01-01-24
Isotretinoins 2024 PA Fax 1430-A V1 01-01-24
Ivermectin Tab 2024 PA Fax 4922-A V1 01-01-24
IVIG BDC 2024 PA Fax 119-A BD-15 V1 01-01-24
J
Jakafi 2024 PA Fax 723-A V1 01-01-24
Jaypirca 2024 PA Fax 5769-A V1 01-01-24
Jynneos 2024 PA Fax BD-25 V1 01-01-24
K
Kalydeco 2024 PA Fax 753-A V2 01-01-24
Kesimpta 2024 PA Fax 4122-A V1 01-01-24
Ketoconazole PO 2024 PA Fax 1440-A V1 01-01-24
Kevzara 2024 PA Fax 1958-A V3 01-01-24
Keytruda 2024 PA Fax 1185-A V7 01-01-24
Kisqali-Kisqali Femara 2024 PA Fax 1638-A V3 01-01-24
Korlym 2024 PA Fax 778-A V1 01-01-24
Koselugo 2024 PA Fax 3771-A V1 01-01-24
Krazati 2024 PA Fax 5702-A V1 01-01-24
L
Lenvima 2024 PA Fax 1248-A V1 01-01-24
Leuprolide Inj 2024 PA Fax 4629-A V3 01-01-24
Lidocaine Topical 2024 PA Fax 1434-A V2 01-01-24
Lidoderm ZTLido 2024 PA Fax 1433-A V1 01-01-24
Lonsurf 2024 PA Fax 1298-A V1 01-01-24
Lorbrena 2024 PA Fax 2788-A V1 01-01-24
Lotronex 2024 PA Fax 1435-A V1 01-01-24
Lovaza 2024 PA Fax 2480-A V1 01-01-24
Lumakras 2024 PA Fax 4762-A V1 01-01-24
Lumizyme 2024 PA Fax 593-A V1 01-01-24
Lupron Endometriosis 2024 PA Fax 567-A V2 01-01-24
Lupron PED 2024 PA Fax 549-A V1 01-01-24
Lynparza 2024 PA Fax 1232-A V4 01-01-24
Lyrica 2024 PA Fax 2898-A V2 01-01-24
Lytgobi 2024 PA Fax 5648-A V2 01-01-24
M
Mavyret 2024 PA Fax 2243-A V2 01-01-24
Megestrol 2024 PA Fax 1437-A V1 01-01-24
Mekinist 2024 PA Fax 999-A V3 01-01-24
Mektovi 2024 PA Fax 2613-A V2 01-01-24
Methylphenidate 2024 PA Fax 3642-A V1 01-01-24
Methyltestosterone 2024 PA Fax 3707-A V1 01-01-24
Miglustat 2024 PA Fax 580-A V2 01-01-24
Monjuvi 2024 PA Fax 4057-A V2 01-01-24
N
Naglazyme 2024 PA Fax 577-A V1 01-01-24
Namenda 2024 PA Fax 1439-B V1 01-01-24
Natpara 2024 PA Fax 1263-A V1 01-01-24
Nebs-Asthma COPD 2024 PA Fax BD-8 V2 01-01-24
Nebs-Mucolytics 2024 PA Fax BD-10 V2 01-01-24
Nebs-Pentamidine 2024 PA Fax BD-11 V1 01-01-24
Nerlynx 2024 PA Fax 2180-A V1 01-01-24
Nexavar 2024 PA Fax 417-A V1 01-01-24
Ninlaro 2024 PA Fax 1312-A V1 01-01-24
Nitisinone 2024 PA Fax 579-A V1 01-01-24
Northera 2024 PA Fax 1142-A V1 01-01-24
Noxafil Sus 2024 PA Fax 4505-A V1 01-01-24
Noxafil Tab 2024 PA Fax 4504-A V1 01-01-24
Nubeqa 2024 PA Fax 3149-A V2 01-01-24
Nuedexta 2024 PA Fax 1441-A V1 01-01-24
Nulojix 2024 PA Fax BD-26 V1 01-01-24
Nuplazid 2024 PA Fax 1366-A V1 01-01-24
Nurtec ODT 2024 PA Fax 4556-A V1 01-01-24
Nuvigil 2024 PA Fax 1442-A V1 01-01-24
O
Octreotide 2024 PA Fax 4361-A V1 01-01-24
Odomzo 2024 PA Fax 1283-A V1 01-01-24
Ofev 2024 PA Fax 1216-A V1 01-01-24
Ojjaara 2024 PA Fax 6190-A V1 01-01-24
Onureg 2024 PA Fax 4196-A V1 01-01-24
Opioids ER 2024 PA Fax 2493-A V2 01-01-24
Opsumit 2024 PA Fax 1049-A V1 01-01-24
Oral Chemo 2024 PA Fax BD-17 V1 01-01-24
Oral Intranasal Fentanyl 2024 PA Fax 1445-A V1 01-01-24
Orgovyx 2024 PA Fax 4413-A V1 01-01-24
Orkambi 2024 PA Fax 1279-A V1 01-01-24
Orserdu 2024 PA Fax 5776-A V1 01-01-24
Otezla 2024 PA Fax 1129-A V1 01-01-24
Ozempic 2024 PA Fax 5569-A V2 01-01-24
P
Panretin 2024 PA Fax 4861-A V1 01-01-24
Parenteral Nutrition 2024 PA Fax BD-18 V1 01-01-24
Paxil Sus 2024 PA Fax 4617-A V1 01-01-24
Pegasys 2024 PA Fax 556-A V2 01-01-24
Pegfilgrastim 2024 PA Fax 153-A V2 01-01-24
Pemazyre 2024 PA Fax 3823-A V3 01-01-24
Phenylbutyrate 2024 PA Fax V2 01-01-24
Phesgo 2024 PA Fax 3987-A V1 01-01-24
Piqray 2024 PA Fax 3090-A V1 01-01-24
Pomalyst 2024 PA Fax 963-A V1 01-01-24
Prevymis 2024 PA Fax 4788-A V3 01-01-24
Promacta 2024 PA Fax 592-A V2 01-01-24
Provigil 2024 PA Fax 1450-A V1 01-01-24
Pulmozyme BDC 2024 PA Fax 563-A BD-10 V1 01-01-24
Q
Qinlock 2024 PA Fax 3902-A V2 01-01-24
Qualaquin 2024 PA Fax 1451-A V1 01-01-24
Qulipta 2024 PA Fax 5001-A V3 01-01-24
R
Rabies Vaccine 2024 PA Fax BD-23 V1 01-01-24
Regranex 2024 PA Fax 1453-A V1 01-01-24
Relistor Inj 2024 PA Fax 1454-A V1 01-01-24
Renflexis 2024 PA Fax 3947-A V1 01-01-24
Repatha 2024 PA Fax 1774-A V1 01-01-24
Retevmo 2024 PA Fax 3875-A V3 01-01-24
Revlimid 2024 PA Fax 386-A V1 01-01-24
Rezlidhia 2024 PA Fax 5684-A V2 01-01-24
Rezurock 2024 PA Fax 4854-A V1 01-01-24
Rinvoq 2024 PA Fax 3186-A V2 01-01-24
Rozlytrek 2024 PA Fax 3166-A V2 01-01-24
Rubraca 2024 PA Fax 1569-A V2 01-01-24
Rybelsus 2024 PA Fax 5570-A V2 01-01-24
Rydapt 2024 PA Fax 1818-A V1 01-01-24
S
Sapropterin 2024 PA Fax 341-A V1 01-01-24
Savella 2024 PA Fax 3534-A V1 01-01-24
Scemblix 2024 PA Fax 5048-A V1 01-01-24
Seroquel XR 2024 PA Fax 2875-A V1 01-01-24
Signifor 2024 PA Fax 970-A V1 01-01-24
Sildenafil PO 2024 PA Fax 641-A V2 01-01-24
Sirturo 2024 PA Fax 1456-A V1 01-01-24
Skyrizi 2024 PA Fax 3048-A V1 01-01-24
Somatuline Depot 2024 PA Fax 671-A V1 01-01-24
Somavert 2024 PA Fax 564-A V1 01-01-24
Sporanox Capsules 2024 PA Fax 1432-A V1 01-01-24
Sprycel 2024 PA Fax 422-A V1 01-01-24
Stelara 2024 PA Fax 560-A V4 01-01-24
Stivarga 2024 PA Fax 820-A V2 01-01-24
Sutent 2024 PA Fax 418-A V2 01-01-24
Symdeko 2024 PA Fax 2515-A V1 01-01-24
Synarel 2024 PA Fax 5802-A V1 01-01-24
Synribo 2024 PA Fax 886-A V2 01-01-24
Syprine 2024 PA Fax 2486-A V1 01-01-24
T
Tabrecta 2024 PA Fax 3879-A V1 01-01-24
Tafinlar 2024 PA Fax 1000-A V2 01-01-24
Tagrisso 2024 PA Fax 1305-A V2 01-01-24
Taltz 2024 PA Fax 1351-A V1 01-01-24
Talzenna 2024 PA Fax 2781-A V3 01-01-24
Tarceva 2024 PA Fax 223-A V1 01-01-24
Targretin caps 2024 PA Fax 507-A V1 01-01-24
Targretin Gel 2024 PA Fax 4618-A V1 01-01-24
Tasigna 2024 PA Fax 421-A V1 01-01-24
Tazorac 2024 PA Fax 1462-A V1 01-01-24
Tazverik 2024 PA Fax 3503-A V1 01-01-24
Tecentriq 2024 PA Fax 1374-A V3 01-01-24
Temazepam 2024 PA Fax 3501-B V1 01-01-24
Tepmetko 2024 PA Fax 4496-A V1 01-01-24
Teriparatide 2024 PA Fax 94-A V2 01-01-24
Testosterone Cypionate 2024 PA Fax 1464-A V1 01-01-24
Testosterone Enanthate 2024 PA Fax 1463-A V1 01-01-24
Testosterone Topical 2024 PA Fax 1465-A V1 01-01-24
Tetanus Vaccine 2024 PA Fax BD-19 V1 01-01-24
Tetracycline 2024 PA Fax 3541-A V1 01-01-24
Thalomid 2024 PA Fax 230-A V1 01-01-24
Tibsovo 2024 PA Fax 2637-A V2 01-01-24
Tobramycin BDC 2024 PA Fax 232-A BD-12 V1 01-01-24
Tracleer 2024 PA Fax 234-A V1 01-01-24
Tranxene T 2024 PA Fax 1466-B V1 01-01-24
Trastuzumab BDC 2024 PA Fax 1499-A BD-13 V2 01-01-24
Trazimera BDC 2024 PA Fax 3945-A BD-13 V2 01-01-24
Treprostinil BDC 2024 PA Fax 188-A BD-20 V1 01-01-24
Tretinoins Topical 2024 PA Fax 1467-A V1 01-01-24
Trikafta 2024 PA Fax 3375-A V2 01-01-24
Trulicity 20]24 PA Fax 5571-A V2 01-01-24
Truxima 2024 PA Fax 4710-A V3 01-01-24
Tukysa 2024 PA Fax 3781-A V2 01-01-24
Turalio 2024 PA Fax 3152-A V1 01-01-24
Tykerb 2024 PA Fax 308-A V1 01-01-24
U
Ubrelvy 2024 PA Fax 3485-A V1 01-01-24
Uceris 2024 PA Fax 4500-A V1 01-01-24
Uloric 2024 PA Fax 2885-A V1 01-01-24
V
Valchlor 2024 PA Fax 1044-A V1 01-01-24
Vanflyta 2024 PA Fax 6087-A V1 01-01-24
Velcade BDC 2024 PA Fax 763-A BD-13 V1 01-01-24
Venclexta 2024 PA Fax 1353-A V1 01-01-24
Ventavis BDC 2024 PA Fax 240-A BD-9. V1 01-01-24
Versacloz 2024 PA Fax 4553-A V2 01-01-24
Verzenio 2024 PA Fax 2343-A V2 01-01-24
Vfend 2024 PA Fax 2877-A V1 01-01-24
Vigabatrin 2024 PA Fax 548-A V2 01-01-24
Vitamin D Topical 2024 PA Fax 2569-A V1 01-01-24
Vitrakvi 2024 PA Fax 2801-A V1 01-01-24
Vizimpro 2024 PA Fax 2771-A V1 01-01-24
Vonjo 2024 PA Fax 5264-A V2 01-01-24
Vosevi 2024 PA Fax 2177-A V1 01-01-24
Votrient 2024 PA Fax 547-A V2 01-01-24
Vyvanse 2024 PA Fax 3674-A V2 01-01-24
W
Welireg 2024 PA Fax 4902-A V1 01-01-24
X
Xalkori 2024 PA Fax 697-A V2 01-01-24
Xeljanz 2024 PA Fax 914-A V1 01-01-24
Xenazine 2024 PA Fax 360-A V2 01-01-24
Xermelo 2024 PA Fax 1671-A V1 01-01-24
Xgeva BDC 2024 PA Fax 637-A BD-13 V1 01-01-24
Xhance 2024 PA Fax 4539-A V2 01-01-24
Xifaxan 550mg 2024 PA Fax 1480-A V1 01-01-24
Xolair 2024 PA Fax 473-A V3 01-01-24
Xospata 2024 PA Fax 2808-A V1 01-01-24
Xpovio 2024 PA Fax 3121-A V1 01-01-24
Xtandi 2024 PA Fax 816-A V1 01-01-24
Xyrem 2024 PA Fax 1481-A V2 01-01-24
Y
There are no drugs beginning with the letter Y that require prior authorization at this time.
Z
Zarxio 2024 PA Fax 4507-A V1 01-01-24
Zejula 2024 PA Fax 1689-A V2 01-01-24
Zelboraf 2024 PA Fax 696-A V2 01-01-24
Zirabev BDC 2024 PA Fax 3944-A BD-13 V3 01-01-24
Zolinza 2024 PA Fax 566-A V1 01-01-24
Zonisade 2024 PA Fax 5624-A V1 01-01-24
Ztalmy 2024 PA Fax 5338-A V1 01-01-24
Zydelig 2024 PA Fax 1174-A V1 01-01-24
Zykadia 2024 PA Fax 1136-A V1 01-01-24