2018 Prior Authorization Forms

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

ACTIMMUNE 2018 PA FAX 562-A V1 01-01-18

ADAGEN 2018 PA FAX 572-A V1 01-01-18

ADCIRCA 2018 PA FAX 639-A V1 01-01-18

ADEMPAS 2018 PA FAX 1048-A V1 01-01-18

AFINITOR 2018 PA FAX 415-A V1 01-01-18

ALDURAZYME 2018 PA FAX 573-A V1 01-01-18

ALECENSA 2018 PA FAX 1322-A V1 01-01-18

ALPHA1-PROTEINASE INHIBITORS 2018 PA FAX 11-A V1 01-01-18

ALUNBRIG 2018 PA FAX 1816-A V1 01-01-18

AMPYRA 2018 PA FAX 477-A V1 01-01-18

ANADROL 2018 PA FAX 1495-A V1 01-01-18

ANTIEMETICS 2018 PA FAX BD-16 V2 01-01-18

APOKYN 2018 PA FAX 22-A V1 01-01-18

ARCALYST 2018 PA FAX 597-A V1 01-01-18

AVASTIN BDCLIN 2018 PA FAX 799-A BD-13 V1 01-01-18

BANZEL 2018 PA FAX 1386-A V1 01-01-18

BELEODAQ 2018 PA FAX 1165-A V1 01-01-18

BENYLSTA 2018 PA FAX 862-A V1 01-01-18

BETASERON-EXTAVIA 2018 PA FAX 543-A V1 01-01-18

BOSULIF 2018 PA FAX 806-A V1 01-01-18

BRIVIACT 2018 PA FAX 1500-A V2 01-01-18

BUPHENYL 2018 PA FAX 965-A V1 01-01-18

BUPRENORPHINE 2018 PA FAX 1391-A V1 01-01-18

BUPRENORPHINE-NALOXONE 2018 PA FAX 1392-A V1 01-01-18

CABOMETYX 2018 PA FAX 1367-A V1 01-01-18

CAPRELSA 2018 PA FAX 801-A V2 01-01-18

CARBAGLU 2018 PA FAX 840-A V1 01-01-18

CAYSTON 2018 PA FAX 480-A V1 01-01-18

CERDELGA 2018 PA FAX 1188-A V1 01-01-18

CEREZYME 2018 PA FAX 1497-A V1 01-01-18

CHANTIX 2018 PA FAX 1393-A V1 01-01-18

CINRYZE 2018 PA FAX 359-A V1 01-01-18

COMETRIQ 2018 PA FAX 916-A V2 01-01-18

COPAXONE-GLATOPA 2018 PA FAX 544-A V1 01-01-18

COTELLIC 2018 PA FAX 1307-A V1 01-01-18

CYSTAGON 2018 PA FAX 803-A V1 01-01-18

CYSTARAN 2018 PA FAX 926-A V1 01-01-18

DAKLINZA 2018 PA FAX 1284-A V1 01-01-18

DURAGESIC 2018 PA FAX 1398-A V1 01-01-18

EMEND VARUBI 2018 PA FAX BD-3 V2 01-01-18

EMSAM 2018 PA FAX 1401-A V1 01-01-18

EPCLUSA 2018 PA FAX 1508-A V2 01-01-18

EPOGEN-PROCRIT 2018 PA FAX 81-A V1 01-01-18

ERIVEDGE 2018 PA FAX 762-A V1 01-01-18

ESBRIET 2018 PA FAX 1217-A V1 01-01-18

EXJADE-JADENU 2018 PA FAX 553-A V1 01-01-18

FABRAZYME 2018 PA FAX 576-A V1 01-01-18

FARYDAK 2018 PA FAX 1247-A V1 01-01-18

FAZACLO 2018 PA FAX 1403-A V1 01-01-18

FIRAZYR 2018 PA FAX 809-A V1 01-01-18

FORTEO 2018 PA FAX 94-A V1 01-01-18

FYCOMPA 2018 PA FAX 1406-A V1 01-01-18

GATTEX 2018 PA FAX 938-A V1 01-01-18

GILENYA 2018 PA FAX 620-A V1 01-01-18

GILOTRIF 2018 PA FAX 1011-A V1 01-01-18

GLEEVEC 2018 PA FAX 99-A V1 01-01-18

GROWTH HORMONE 2018 PA FAX 101-A V2 01-01-18

HARVONI 2018 PA FAX 1209-A V2 01-01-18

HEPATITIS B 2018 PA FAX BD-5 V2 01-01-18

HERCEPTIN BDCLIN 2018 PA FAX 1499-A BD-13 V1 01-01-18

HETLIOZ 2018 PA FAX 1125-A V1 01-01-18

HRM LOW IMPACT 2018 PA FAX 1422-A V1 01-01-18

HRM ANTICONVULSANTS 2018 PA FAX 1410-A V1 01-01-18

HRM-ANTIDEPRESSANTS TCA 2018 PA FAX 1412-A V1 01-01-18 

HRM-ANTIPARKINSON 2018 PA FAX 1416-A V1 01-01-18

HRM-ANTIPSYCHOTICS 2018 PA FAX 1417-A V1 01-01-18

HRM-CLOMIPRAMINE 2018 PA FAX 1411-A V1 01-01-18

HRM-HYDROXYZINE 2018 PA FAX 1414-A V1 01-01-18

HRM-HYDROXYZINE INJ 2018 PA FAX 1415-A V1 01-01-18

HRM-HYPNOTICS 2018 PA FAX 1421-A V1 01-01-18

HRM-NITROFURANTOIN 2018 PA FAX 1419-A V1 01-01-18

HRM-PROMETHAZINE 2018 PA FAX 1413-A V1 01-01-18

HRM-SKELETAL MUSCLE RELAXANTS 2018 PA FAX 1420-A V1 01-01-18

HUMIRA 2018 PA FAX 107-A V1 01-01-18

HYPNOTIC BENZODIAZEPINES 2018 PA FAX 1427-B V1 01-01-18

IBRANCE 2018 PA FAX 1236-A V1 01-01-18

ICLUSIG 2018 PA FAX 920-A V1 01-01-18

IMBRUVICA 2018 PA FAX 1050-A V2 01-01-18

IMMUNOSUPPRESSANTS 2018 PA FAX BD-6 V2 01-01-18

INCRELEX 2018 PA FAX 551-A V1 01-01-18

INFUSION 2018 PA FAX BD-20 V2 01-01-18

INHALATION BETA 2 AG ANTICHOL CORTICO MAST CELL 2018 PA FAX BD-8 V1 01-01-18

INJECTABLE 2018 PA FAX BD-13 V2 01-01-18

INLYTA 2018 PA FAX 747-A V1 01-01-18

IRESSA 2018 PA FAX 1282-A V1 01-01-18

ISOTRETINOIN 2018 PA FAX 1430-A V1 01-01-18

IVIG BDCLIN 2018 PA FAX 119-A BD-15 V2 01-01-18

JAKAFI 2018 PA FAX 723-A V1 01-01-18

JUXTAPID 2018 PA FAX 925-A V1 01-01-18

KALYDECO 2018 PA FAX 753-A V2 01-01-18

KEYTRUDA 2018 PA FAX 1185-A V2 01-01-18

KISQALI 2018 PA FAX 1638-A V1 01-01-18

KORLYM 2018 PA FAX 778-A V1 01-01-18

KUVAN 2018 PA FAX 341-A V1 01-01-18

KYNAMRO 2018 PA FAX 937-A V1 01-01-18

LENVIMA 2018 PA FAX 1248-A V1 01-01-18

LETAIRIS 2018 PA FAX 640-A V1 01-01-18

LIDODERM 2018 PA FAX 1433-A V1 01-01-18

LONSURF 2018 PA FAX 1298-A V1 01-01-18

LOTRONEX 2018 PA FAX 1435-A V1 01-01-18

LUMIZYME 2018 PA FAX 593-A V1 01-01-18

LUPRON ENDOMETRIOSIS 2018 PA FAX 567-A V1 01-01-18

LUPRON PROSTATE 2018 PA FAX 347-A V1 01-01-18

LUPRON PUBERTY 2018 PA FAX 549-A V2 01-01-18

LYNPARZA 2018 PA FAX 1232-A V1 01-01-18

MEGACE ES 2018 PA FAX 1437-A V1 01-01-18

MEKINIST 2018 PA FAX 999-A V1 01-01-18

MOZOBIL 2018 PA FAX 389-A V1 01-01-18

MUCOLYTICS 2018 PA FAX BD-10 V1 01-01-18

NAGLAZYME 2018 PA FAX 577-A V1 01-01-18

NAMENDA 2018 PA FAX 1439-B V1 01-01-18

NATPARA 2018 PA FAX 1263-A V2 01-01-18

NEUPOGEN GRANIX ZARXIO 2018 PA FAX 154-A V1 01-01-18

NEXAVAR 2018 PA FAX 417-A V1 01-01-18

NINLARO 2018 PA FAX 1312-A V1 01-01-18

NIZORAL 2018 PA FAX 1440-A V1 01-01-18

NORTHERA 2018 PA FAX 1142-A V1 01-01-18

NUEDEXTA 2018 PA FAX 1441-A V1 01-01-18

NUPLAZID 2018 PA FAX 1366-A V1 01-01-18

NUVIGIL 2018 PA FAX 1442-A V1 01-01-18

OCTREOTIDE SANDOSTATIN 2018 PA FAX 1183-A V1 01-01-18

ODOMZO 2018 PA FAX 1283-A V1 01-01-18

OFEV 2018 PA FAX 1216-A V1 01-01-18

ONFI 2018 PA FAX 1443-A V1 01-01-18

OPSUMIT 2018 PA FAX 1049-A V1 01-01-18

ORAL CHEMOTHERAPY 2018 PA FAX BD-17 V2 01-01-18

ORAL-INTRANASAL FENTANYL 2018 PA FAX 1445-A V1 01-01-18

ORFADIN 2018 PA FAX 579-A V1 01-01-18

ORKAMBI 2018 PA FAX 1279-A V1 01-01-18

OXANDRIN 2018 PA FAX 1384-A V1 01-01-18

PEGASYS 2018 PA FAX 556-A V2 01-01-18

PENTAMIDINE 2018 PA FAX BD-11 V1 01-01-18

POMALYST 2018 PA FAX 963-A V1 01-01-18

PRALUENT 2018 PA FAX 1280-A V2 01-01-18

PROMACTA 2018 PA FAX 592-A V1 01-01-18

PROVIGIL 2018 PA FAX 1450-A V1 01-01-18

PULMOZYME BDCLIN 2018 PA FAX 563-A BD-10 V1 01-01-18

QUALAQUIN 2018 PA FAX 1451-A V1 01-01-18

REGRANEX 2017 PA FAX 1453-A V2 01-01-18

RELISTOR INJ 2018 PA FAX 1454-A V2 01-01-18

REMICADE INFLECTRA RENFLEXIS 2018 PA FAX 187-A V2 01-01-18

REMODULIN BDCLIN 2018 PA FAX 188-A BD-20 V1 01-01-18

REVLIMID 2018 PA FAX 386-A V1 01-01-18

RITUXAN 2018 PA FAX 194-A V1 01-01-18

RUBRACA 2018 PA FAX 1569-A V1 01-01-18

RYDAPT 2018 PA FAX 1818-A V1 01-01-18

SABRIL 2018 PA FAX 548-A V1 01-01-18

SIGNIFOR 2018 PA FAX 970-A V1 01-01-18

SILDENAFIL REVATIO ORAL 2018 PA FAX 641-A V1 01-01-18

SIRTURO 2018 PA FAX 1456-A V1 01-01-18

SOMATULINE DEPOT 2018 PA FAX 671-A V2 01-01-18

SOMAVERT 2018 PA FAX 564-A V1 01-01-18

SORIATANE 2018 PA FAX 1459-A V1 01-01-18

SOVALDI 2018 PA FAX 1089-A V2 01-01-18

SPORANOX 2018 PA FAX 1432-A V1 01-01-18

SPRYCEL 2018 PA FAX 422-A V1 01-01-18

STIVARGA 2018 PA FAX 820-A V1 01-01-18

SUTENT 2018 PA FAX 418-A V1 01-01-18

SYLATRON 2018 PA FAX 660-A V1 01-01-18

SYNRIBO 2018 PA FAX 886-A V1 01-01-18

TAFINLAR 2018 PA FAX 1000-A V1 01-01-18

TAGRISSO 2018 PA FAX 1305-A V1 01-01-18

TARCEVA 2018 PA FAX 223-A V1 01-01-18

TARGRETIN 2018 PA FAX 507-A V1 01-01-18

TASIGNA 2018 PA FAX 421-A V1 01-01-18

TAZORAC 2018 PA FAX 1462-A V1 01-01-18

TECENTRIQ 2018 PA FAX 1374-A V1 01-01-18

TESTOSTERONE CYPIONATE INJ 2018 PA FAX 1464-A V2 01-01-18

TESTOSTERONE ENANTHATE INJ 2018 PA FAX 1463-A V1 01-01-18

TETANUS VACCINE 2018 PA FAX BD-19 V2 01-01-18

THALOMID 2018 PA FAX 230-A V1 01-01-18

TOBRAMYCIN BDCLIN 2018 PA FAX 232-A BD-12 V1 01-01-18

TOPICAL LIDOCAINE 2018 PA FAX 1434-A V1 01-01-18

TOPICAL TESTOSTERONES 2018 PA FAX 1465-A V1 01-01-18

TOPICAL TRETINOIN 2018 PA FAX 1467-A V1 01-01-18

TPN 2018 PA FAX BD-18 V2 01-01-18

TRACLEER 2018 PA FAX 234-A V2 01-01-18

TRANXENE T 2018 PA FAX 1466-B V1 01-01-18

TRELSTAR 2018 PA FAX 283-A V1 01-01-18

TYKERB 2018 PA FAX 308-A V1 01-01-18

TYSABRI 2018 PA FAX 239-A V1 01-01-18

VALCHLOR 2018 PA FAX 1044-A V1 01-01-18

VALIUM 2018 PA FAX 1473-B V1 01-01-18

VELCADE BDCLIN 2018 PA FAX 763-A BD-13 V1 01-01-18

VENCLEXTA 2018 PA FAX 1353-A V1 01-01-18

VENTAVIS BDCLIN 2018 PA FAX 240-A BD-9 V1 01-01-18

VERSACLOZ 2018 PA FAX 1474-A V1 01-01-18

VOLTAREN GEL 2018 PA FAX 1479-A V1 01-01-18

VOTRIENT 2018 PA FAX 547-A V1 01-01-18

VRAYLAR 2018 PA FAX 1592-A V1 01-01-18

XALKORI 2018 PA FAX 697-A V1 01-01-18

XELJANZ 2018 PA FAX 914-A V1 01-01-18

XENAZINE 2018 PA FAX 360-A V1 01-01-18

XGEVA BDCLIN 2018 PA FAX 637-A BD-13 V1 01-01-18

XIFAXAN 2018 PA FAX 1480-A V1 01-01-18

XOLAIR 2018 PA FAX 473-A V1 01-01-18

XTANDI 2018 PA FAX 816-A V1 01-01-18

XYREM 2018 PA FAX 1481-A V1 01-01-18

YERVOY 2018 PA FAX 841-A V1 01-01-18

ZAVESCA 2018 PA FAX 580-A V1 01-01-18

ZEJULA 2018 PA FAX 1689-A V1 01-01-18

ZELBORAF 2018 PA FAX 696-A V2 01-01-18

ZOLINZA 2018 PA FAX 566-A V1 01-01-18

ZYDELIG 2018 PA FAX 1174-A V1 01-01-18

ZYKADIA 2018 PA FAX 1136-A V2 01-01-18

ZYPREXA RELPREVV 2018 PA FAX 1483-A V1 01-01-18

ZYTIGA 2018 PA FAX 661-A V1 01-01-18




Updated 01/2018