2017 Prior Authorization Forms

Click any drug name below to view the corresponding prior authorization fax form.

ACTEMRA 2017 PA FAX 493-A V1 01-01-17

ACTHAR HP 2017 PA FAX 323-A V1 01-01-17

ADAGEN 2017 PA FAX 572-A V1 01-01-17

ADCIRCA 2017 PA FAX 639-A V1 01-01-17

ADCIRCA REVATIO SILDENAFIL EGWP BVD PLUS 2016 2017 PA FAX 1204-A 01-01-17

ADEMPAS 2017 PA FAX 1048-A V1 01-01-17

AFINITOR 2017 PA FAX 415-A V1 01-01-17

AKYNZEO 2017 PA FAX BD-22 V1 01-01-17

ALDURAZYME 2017 PA FAX 573-A V1 01-01-17

ALECENSA 2017 PA FAX 1322-A V1 01-01-17

ALPHA1-PROTEINASE INHIBITORS 2017 PA FAX 11-A V1 01-01-17

AMPYRA 2017 PA FAX 477-A V1 01-01-17

ANADROL 2017 PA FAX 1495-A V1 01-01-17

ANTIEMETICS 2017 PA FAX BD-16 V1 01-01-17

APOKYN 2017 PA FAX 22-A V1 01-01-17

ARANESP 2017 PA FAX 23-A V1 01-01-17

ARCALYST 2017 PA FAX 597-A V1 01-01-17

AUBAGIO 2017 PA FAX 815-A V1 01-01-17

AVEED 2017 PA FAX 1123-A V1 01-01-17

AVEED EGWP BVD PLUS 2016 2017 PA FAX 1304-A V1 01-01-17

AVONEX 2017 PA FAX 31-A V1 01-01-17

BANZEL 2017 PA FAX 1386-A V1 01-01-17

BELBUCA 2017 PA FAX 1387-A V1 01-01-17

BELEODAQ 2017 PA FAX 1165-A V1 01-01-17

BENYLSTA 2017 PA FAX 862-A V1 01-01-17

BERINERT 2017 PA FAX 860-A V1 01-01-17

BETASERON-EXTAVIA 2017 PA FAX 543-A V1 01-01-17

BOSULIF 2017 PA FAX 806-A V1 01-01-17

BOTOX 2017 PA FAX 800-A V1 01-01-17

BOTOX EGWP BVD PLUS 2016a 2017 PA FAX 1205-A V1 01-01-17

BUPHENYL 2017 PA FAX 965-A V1 01-01-17

BUPRENORPHINE 2017 PA FAX 1391-A V1 01-01-17

BUPRENORPHINE-NALOXONE 2017 PA FAX 1392-A V1 01-01-17

CAPRELSA 2017 PA FAX 801-A V1 01-01-17

CARBAGLU 2017 PA FAX 840-A V1 01-01-17

CAYSTON 2017 PA FAX 480-A V1 01-01-17

CERDELGA 2017 PA FAX 1188-A V1 01-01-17

CEREZYME 2017 PA FAX 1497-A V1 01-01-17

CHANTIX 2017 PA FAX 1393-A V1 01-01-17

CHF-ENTRESTO 2017 PA FAX 1402-A V1 01-01-17

CHORIONIC GONADOTROPIN 2017 PA FAX 545-A V1 01-01-17

CIMZIA 2017 PA FAX 552-A V1 01-01-17

CINRYZE 2017 PA FAX 359-A V1 01-01-17

COMETRIQ 2017 PA FAX 916-A V1 01-01-17

COPAXONE-GLATOPA 2017 PA FAX 544-A V1 01-01-17

COSENTYX 2017 PA FAX 1237-A V1 01-01-17

COTELLIC 2017 PA FAX 1307-A V1 01-01-17

CYRAMZA 2017 PA FAX 1143-A V1 01-01-17

CYSTAGON 2017 PA FAX 803-A V1 01-01-17

CYSTARAN 2017 PA FAX 926-A V1 01-01-17

DAKLINZA 2017 PA FAX 1284-A V1 01-01-17

DARAPRIM 2017 PA FAX 1395-A V1 01-01-17

DARZALEX 2017 PA FAX PENDING V1 01-01-17

DURAGESIC 2017 PA FAX 1398-A V1 01-01-17

DYSPORT 2017 PA FAX  468-A V1 01-01-17

DYSPORT EGWP BVD PLUS 2016 2017 PA FAX 1303-A V1 01-01-17

EGRIFTA 2017 PA FAX 689-A V1 01-01-17

ELAPRASE 2017 PA FAX 575-A V1 01-01-17

ELELYSO 2017 PA FAX 839-A V1 01-01-17

EMEND VARUBI 2017 PA FAX BD-3 V1 01-01-17

EMPLICITI 2017 PA FAX 1313-A V1 01-01-17

EMSAM 2017 PA FAX 1401-A V1 01-01-17

ENBREL 2017 PA FAX 80-A V1 01-01-17

ENTRESTO 2017 PA FAX 1402-A V1 01-01-17

ENTYVIO 2017 PA FAX 1155-A V1 01-01-17

EPOGEN-PROCRIT 2017 PA FAX 81-A V1 01-01-17

ERIVEDGE 2017 PA FAX 762-A V1 01-01-17

ERWINAZE 2017 PA FAX 882-A V1 01-01-17

ESBRIET 2017 PA FAX 1217-A V1 01-01-17

EXJADE-JADENU 2017 PA FAX 553-A V1 01-01-17

EYLEA 2017 PA FAX 811-A V1 01-01-17

FABRAZYME 2017 PA FAX 576-A V1 01-01-17

FARYDAK 2017 PA FAX 1247-A V1 01-01-17

FAZACLO 2017 PA FAX 1403-A V1 01-01-17

FERRIPROX 2017 PA FAX 785-A V1 01-01-17

FIRAZYR 2017 PA FAX 809-A V1 01-01-17

FOLOTYN 2017 PA FAX 850-A V1 01-01-17

FORTEO 2017 PA FAX 94-A V1 01-01-17

FYCOMPA 2017 PA FAX 1406-A V1 01-01-17

GATTEX 2017 PA FAX 938-A V1 01-01-17

GAZYVA 2017 PA FAX 1051-A V1 01-01-17

GILENYA 2017 PA FAX 620-A V1 01-01-17

GILOTRIF 2017 PA FAX 1011-A V1 01-01-17

GLEEVEC 2017 PA FAX 99-A V1 01-01-17

GRASTEK 2017 PA FAX 1407-A V1 01-01-17

GROWTH HORMONE 2017 PA FAX 101-A V1 01-01-17

GROWTH HORMONE EGWP BVD PLUS 2016 2017 PA FAX 1206-A V1 01-01-17

HEP C-DAKLINZA 2017 PA FAX 1284-A V1 01-01-17

HEP C-SOVALDI 2017 PA FAX 1089-A V1 01-01-17

HEPATITIS B 2017 PA FAX BD-5 V1 01-01-17

HETLIOZ 2017 PA FAX 1125-A V1 01-01-17

HIGH RISK MEDICATION 2017 PA FAX 1422-A V1 01-01-17

HIGH RISK MEDICATIONS 2017 PA FAX C8778-A V1 01-01-17

HRM ANTICONVULSANTS 2017 PA FAX 1410-A V1 01-01-17

HRM-ANTIDEPRESSANTS TCA 2017 PA FAX 1412-A V1 01-01-17

HRM-ANTIPARKINSON 2017 PA FAX 1416-A V1 01-01-17

HRM-ANTIPSYCHOTICS 2017 PA FAX 1417-A V1 01-01-17

HRM-CLOMIPRAMINE 2017 PA FAX 1411-A V1 01-01-17

HRM-DIGOXIN 2017 PA FAX 1424-A V1 01-01-17

HRM-ESTROGENS 2017 PA FAX 1418-A V1 01-01-17

HRM-GLYBURIDE 2017 PA FAX 1425-A V1 01-01-17

HRM-HYDROXYZINE 2017 PA FAX 1414-A V1 01-01-17

HRM-HYDROXYZINE INJ 2017 PA FAX 1415-A V1 01-01-17

HRM-HYPNOTICS 2017 PA FAX 1421-A V1 01-01-17

HRM-MEGESTROL AC 2017 PA FAX 1426-A V1 01-01-17

HRM-NITROFURANTOIN 2017 PA FAX 1419-A V1 01-01-17

HRM-PROMETHAZINE 2017 PA FAX 1413-A V1 01-01-17

HRM-SKELETAL MUSCLE RELAXANTS 2017 PA FAX 1420-A V1 01-01-17

HUMIRA 2017 PA FAX 107-A V2 01-01-17

HYPNOTIC BENZODIAZEPINES 2017 PA FAX 1427-B V1 01-01-17

HYPNOTICS-HRM 2017 PA FAX C8827-A V1 01-01-17

IBRANCE 2017 PA FAX 1236-A V1 01-01-17

ICLUSIG 2017 PA FAX 920-A V1 01-01-17

ILARIS 2017 PA FAX 423-A V1 01-01-17

IMBRUVICA 2017 PA FAX 1050-A V1 01-01-17

IMMUNOSUPPRESSANTS 2017 PA FAX BD-6 V1 01-01-17

INCRELEX 2017 PA FAX 551-A V1 01-01-17

INFUSION 2017 PA FAX BD-20 V1 01-01-17

INFUSION BD-20 BVDCLIN REMODULIN 2017 PA FAX 188-A V1 01-01-17

INHALATION BETA 2 AG ANTICHOL CORTICO MAST CELL 2017 PA FAX BD-8 V1 01-01-17

INHALATION-ILOPROST-TREPROSTINIL 2017 PA FAX BD-9

INHALATION ILOPROST-TREPOSTINIL BD-9 BVDCLIN VENTAVIS 2017 PA FAX 240-A V1 01-01-17

INHALATION-MUCOLYTICS 2017 PA FAX BD-10 V1 01-01-17

INHALATION MUCOLYTICS BC-10 BVDCLIN PULMOZYME 2017 PA FAX 563-A V1 01-01-17

INHALATION TOBRAMYCIN 2017 PA FAX BD-12

INHALATION TOBRAMYCIN BD-12 BVDCLIN TOBRAMYCIN 2017 PA FAX 232-A V1 01-01-17

INJECTABLE 2017 PA FAX BD-13 V1 01-01-17

INJECTABLE BD-13 BVDCLIN ACTIMMUNE 2017 PA FAX 562-A V1 01-01-17

INJECTABLE BD-13 BVDCLIN AVASTIN 2017 PA FAX 799-A V1 01-01-17

INJECTABLE BD-13 BVDCLIN HERCEPTIN 2017 PA FAX 1499-A V1 01-01-17

INJECTABLE BD-13 BVDCLIN VELCADE 2017 PA FAX 763-A V1 01-01-17

INLYTA 2017 PA FAX 747-A V1 01-01-17

IRESSA 2017 PA FAX 1282-A V1 01-01-17

ISOTRETINOIN 2017 PA FAX 1430-A V1 01-01-17

IVIG 2017 PA FAX BD-15

IVG BD-15 BVDCLIN HIZENTRA 2017 PA FAX 247-A V1 01-01-17

IVG BD-15 BVDCLIN HYQVIA 2017 PA FAX 1257-B V1 01-01-17

IVIG BD-15 BVDCLIN IVIG 2017 PA FAX 119-A V1 01-01-17

IVIG BD-15 BVDCLIN PRIVIGEN 2017 PA FAX 1187-A V1 01-01-17

JAKAFI 2017 PA FAX 723-A V1 01-01-17

JEVTANA 2017 PA FAX 848-A V1 01-01-17

JUXTAPID 2017 PA FAX 925-A V1 01-01-17

JUXTAPID EGWP BVD PLUS 2016 2017 PA FAX 1306-A V1 01-01-17

KALBITOR 2017 PA FAX 812-A V1 01-01-17

KALYDECO 2017 PA FAX 753-A V1 01-01-17

KANUMA 2017 PA FAX 1314-A V1 01-01-17

KEVEYIS 2017 PA FAX 1342-A V1 01-01-17

KEYTRUDA 2017 PA FAX 1185-A V1 01-01-17

KINERET 2017 PA FAX 120-A V1 01-01-17

KORLYM 2017 PA FAX 778-A V1 01-01-17

KUVAN 2017 PA FAX 347-A V1 01-01-17

KYNAMRO 2017 PA FAX 937-A V1 01-01-17

LEMTRADA 2017 PA FAX 1223-A V1 01-01-17

LENVIMA 2017 PA FAX 1248-A V1 01-01-17

LETAIRIS 2017 PA FAX 640-A V1 01-01-17

LEUKINE 2017 PA FAX 123-A V1 01-01-17

LIDODERM 2017 PA FAX 1433-A V1 01-01-17

LIDODERM EGWP BVD PLUS 01-2016 2017 PA FAX 1197-A V1 01-01-17

LONSURF 2017 PA FAX 1298-A V1 01-01-17

LOTRONEX 2017 PA FAX 1435-A V1 01-01-17

LUCENTIS 2017 PA FAX 883-A V1 01-01-17

LUMIZYME 2017 PA FAX 593-A V1 01-01-17

LUPANETA 2017 PA FAX 1186-A V1 01-01-17

LUPRON ENDOMETRIOSIS 2017 PA FAX 567-A V1 01-01-17

LYNPARZA 2017 PA FAX 1232-A V1 01-01-17

MEGACE ES 2017 PA FAX 1437-A V1 01-01-17

MEKINIST 2017 PA FAX 999-A V1 01-01-17

MIRCERA 2017 PA FAX 1256-A V1 01-01-17

MOZOBIL 2017 PA FAX 389-A V1 01-01-17

MYALEPT 2017 PA FAX 1145-A V1 01-01-17

NAGLAZYME 2017 PA FAX 577-A V1 01-01-17

NAMENDA EGWP BVD PLUS 05-2015 2017 PA FAX 1198-B V1 01-01-17

NATPARA 2017 PA FAX 1263-A V1 01-01-17

NEULASTA 2017 PA FAX 153-A V1 01-01-17

NEUPOGEN GRANIX ZARXIO 2017 PA FAX 154-A V1 01-01-17

NEXAVAR 2017 PA FAX 417-A V1 01-01-17

NINLARO 2017 PA FAX 1312-A V1 01-01-17

NITROFURANTOIN-HRM 2017 PA FAX C8828-A V1 01-01-17

NIZORAL 2017 PA FAX 1440-A V1 01-01-17

NPLATE 2017 PA FAX 358-A V1 01-01-17

NUCALA 2017 PA FAX 1302-A V1 01-01-17

NUEDEXTA 2017 PA FAX 1441-A V1 01-01-17

NUVIGIL 2017 PA FAX 1422-A V1 01-01-17

OCTREOTIDE SANDOSTATIN 2017 PA FAX 1183-A V1 01-01-17

ODOMZO 2017 PA FAX 1283-A V1 01-01-17

OFEV 2017 PA FAX 1216-A V1 01-01-17

ONCASPAR 2017 PA FAX 846-A V1 01-01-17

ONFI 2017 PA FAX 1443-A V1 01-01-17

ONMEL 2017 PA FAX 1431-A V1 01-01-17

OPDIVO 2017 PA FAX 1224-A V1 01-01-17

OPSUMIT 2017 PA FAX 1049-A V1 01-01-17

ORAL CHEMOTHERAPY 2017 PA FAX BD-17 V1 01-01-17

ORAL-INTRANASAL FENTANYL 2017 PA FAX 1445-A V1 01-01-17

ORAL-INTRANASAL FENTANYL EGWP BVD PLUS 01-2016 2017 PA FAX 1199-A V1 01-01-17

ORALAIR 2017 PA FAX 1444-A V1 01-01-17

ORENCIA 2017 PA FAX 159-A V1 01-01-17

ORENITRAM 2017 PA FAX 1090-A V1 01-01-17

ORFADIN 2017 PA FAX 579-A V1 01-01-17

ORKAMBI 2017 PA FAX 1279-A V1 01-01-17

OTEZLA 2017 PA FAX 1129-A V1 01-01-17

OTREXUP 2017 PA FAX 1124-A V1 01-01-17

OXANDRIN 2017 PA FAX 1384-A V1 01-01-17

OXANDRIN EGWP BVD PLUS 02-2015 2017 PA FAX 1195-A V1 01-01-17

PCSK9-PRALUEND 2017 PA FAX 1280-A V1 01-01-17

PEGASYS 2017 PA FAX 556-A V1 01-01-17

PENTAMIDINE 2017 PA FAX BD-11 V1 01-01-17

PERJETA 2017 PA FAX 789-A V1 01-01-17

PLEGRIDY 2017 PA FAX 1189-A V1 01-01-17

POMALYST 2017 PA FAX 963-A V1 01-01-17

PORTRAZZA 2017 PA FAX 1318-A V1 01-01-17

PRALUENT 2017 PA FAX 1280-A V1 01-01-17

PROCYSBI 2017 PA FAX 1012-A V1 01-01-17

PROMACTA 2017 PA FAX 592-A V1 01-01-17

PROVIGIL 2017 PA FAX 1450-A V1 01-01-17

QUALAQUIN 2017 PA FAX 1451-A V1 01-01-17

RAGWITEK 2017 PA FAX 1452-A V1 01-01-17

RASUVO 2017 PA FAX 1173-A V1 01-01-17

RAVICTI 2017 PA FAX 966-A V1 01-01-17

REBIF 2017 PA FAX 542-A V1 01-01-17

REGRANEX 2017 PA FAX 1453-A V1 01-01-17

RELISTOR 2017 PA FAX 1454-A V1 01-01-17

REMICADE 2017 PA FAX 187-A V1 01-01-17

REVLIMID 2017 PA FAX 386-A V1 01-01-17

RITUXAN 2017 PA FAX 194-A V1 01-01-17

RUCONEST 2017 PA FAX 1180-A V1 01-01-17

SABRIL 2017 PA FAX 548-A V1 01-01-17

SAMSCA 2017 PA FAX 546-A V1 01-01-17

SEROSTIM 2017 PA FAX 485-A V1 01-01-17

SIGNIFOR 2017 PA FAX 970-A V1 01-01-17

SIGNIFOR LAR 2017 PA FAX 1226-A V1 01-01-17

SILDENAFIL REVATIO INJ 2017 PA FAX 1289-A V1 01-01-17

SILDENAFIL REVATIO TAB 2017 PA FAX 641-A V1 01-01-17

SIMPONI 2017 PA FAX 413-A V1 01-01-17

SIRTURO 2017 PA FAX 1456-A V1 01-01-17

SOLARAZE 2017 PA FAX 1458-A V1 01-01-17

SOLIRIS 2017 PA FAX 1291-A V1 01-01-17

SOLODYN 2017 PA FAX 1501-A V1 01-01-17

SOMATULINE DEPOT 2017 PA FAX 671-A V1 01-01-17

SOMAVERT 2017 PA FAX 564-A V1 01-01-17

SORIATANE 2017 PA FAX 1459-A V1 01-01-17

SOVALDI 2017 PA FAX 1089-A V1 01-01-17

SPORANOX 2017 PA FAX 1432-A V1 01-01-17

SPRYCEL 2017 PA FAX 422-A V1 01-01-17

STELARA 2017 PA FAX 560-A V1 01-01-17

STIVARGA 2017 PA FAX 820-A V1 01-01-17

STRENSIQ 2017 PA FAX 1300-A V1 01-01-17

SUTENT 2017 PA FAX 418-A V1 01-01-17

SYLATRON 2017 PA FAX 660-A V1 01-01-17

SYLVANT 2017 PA FAX 1135-A V1 01-01-17

SYMLIN 2017 PA FAX 1461-A V1 01-01-17

SYNRIBO 2017 PA FAX 886-A V1 01-01-17

TAFINLAR 2017 PA FAX 1000-A V1 01-01-17

TAGRISSO 2017 PA FAX 1305-A V1 01-01-17

TARCEVA 2017 PA FAX 223-A V1 01-01-17

TARGRETIN 2017 PA FAX 507-A V1 01-01-17

TASIGNA 2017 PA FAX 421-A V1 01-01-17

TAZORAC 2017 PA FAX 1462-A V1 01-01-17

TECFIDERA 2017 PA FAX 975-A V1 01-01-17

TESTOSTERONE - CYPIONATE EGWP BVD PLUS 11-2015 2017 PA FAX 1274-A V1 01-01-17

TESTOSTERONE - ENANTHATE EGWP BVD PLUS 11-2015 (2) 2017 PA FAX 1275-A V1 01-01-17

TESTOSTERONE CYPIONATE INJ 2017 PA FAX 1464-A V1 01-01-17

TESTOSTERONE ENANTHATE INJ 2017 PA FAX 1463-A V1 01-01-17

TESTOSTERONE - TOP BUCCAL EGWP BVD PLUS 11-2015 (2) 2017 PA FAX 1201-A V1 01-01-17

TETANUS VACCINE 2017 PA FAX BD-19 V1 01-01-17

THALOMID 2017 PA FAX 230-A V1 01-01-17

TOBI INHALER 2017 PA FAX 1507-A V1 01-01-17

TOPICAL LIDOCAINE 2017 PA FAX 1434-A V1 01-01-17

TOPICAL TESTOSTERONES 2017 PA FAX 1465-A V1 01-01-17

TOPICAL TRETINOIN 2017 PA FAX 1467-A V1 01-01-17

TPN 2017 PA FAX BD-18 V1 01-01-17

TRACLEER 2017 PA FAX 234-A V1 01-01-17

TRANXENE T 2017 PA FAX 1466-B V1 01-01-17

TRELSTAR 2017 PA FAX 283-A V1 01-01-17

TYKERB 2017 PA FAX 308-A V1 01-01-17

TYSABRI 2017 PA FAX 239-A V1 01-01-17

UPTRAVI 2017 PA FAX 1323-A V1 01-01-17

VALCHLOR 2017 PA FAX 1044-A V1 01-01-17

VALIUM 2017 PA FAX 1473-B V1 01-01-17

VANTAS 2017 PA FAX 317-A V1 01-01-17

VENCLEXTA 2017 PA FAX 1353-A V1 01-01-17

VERSACLOZ 2017 PA FAX 1474-A V1 01-01-17

VIBERZI 2017 PA FAX 1475-A V1 01-01-17

VIMIZIM 2017 PA FAX 1113-A V1 01-01-17

VOLTAREN GEL 2017 PA FAX 1479-A V1 01-01-17

VOTRIENT 2017 PA FAX 547-A V1 01-01-17

VPRIV 2017 PA FAX 1502-A V1 01-01-17

XALKORI 2017 PA FAX 697-A V1 01-01-17

XELJANZ 2017 PA FAX 914-A V1 01-01-17

XENAZINE 2017 PA FAX 360-A V1 01-01-17

XEOMIN 2017 PA FAX 819-A V1 01-01-17

XEOMIN EGWP BVD PLUS MDC 2016A 2017 PA FAX 1207-A V1 01-01-17

XIFAXAN 2017 PA FAX 1480-A V1 01-01-17

XOLAIR 2017 PA FAX 473-A V1 01-01-17

XTANDI 2017 PA FAX 816-A V1 01-01-17

XYREM 2017 PA FAX 1481-A V1 01-01-17

XYREM EGWP BVD PLUS 11-2015 2017 PA FAX 1202-A V1 01-01-17

YERVOY 2017 PA FAX 841-A V1 01-01-17

ZALTRAP 2017 PA FAX 818-A V1 01-01-17

ZAVESCA 2017 PA FAX 580-A V1 01-01-17

ZELBORAF 2017 PA FAX 696-A V1 01-01-17

ZOLADEX 2017 PA FAX 334-A V1 01-01-17

ZOLINZA 2017 PA FAX 566-A V1 01-01-17

ZORBTIVE 2017 PA FAX 262-A V1 01-01-17

ZYDELIG 2017 PA FAX 1174-A V1 01-01-17

ZYKADIA 2017 PA FAX 1136-A V1 01-01-17

ZYPREXA RELPREVV 2017 PA FAX 1483-A V1 01-01-17

ZYTIGA 2017 PA FAX 661-A V1 01-01-17




Updated 01/2017