Prior Authorization
Prior Authorization is a tool that helps decide whether or not a prescription is covered before it is filled. The approval or denial is based on the plan design and focuses on safety and proper medication use. If a drug on the Trinity Health Plan Of New England formulary requires prior authorization, you will see the abbreviation "PA" in the formulary.
You may also see drugs in the formulary marked with "B/D". This means that the drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
Please have your pharmacist or doctor call CVS Caremark’s Prior Authorization department at 1-800-294-5979 (TTY 711) before prescribing or administering drugs that require prior authorization.
2024 Prior Authorization Criteria (last updated 11/01/2024)
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