2019 Prior Authorization Forms

 

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

 

ACTIMMUNE 2019 PA FAX 562-A V1 01-01-19

ADAGEN 2019 PA FAX 572-A V1 01-01-19

ADEMPAS 2019 PA FAX 1048-A V1 01-01-19

AFINITOR 2019 PA FAX 415-A V1 01-01-19

ALDURAZYME 2019 PA FAX 573-A V1 01-01-19

ALECENSA 2019 PA FAX 1322-A V1 01-01-19

ALPHA1 PROTEINASE INHIBITOR 2019 PA FAX 11-A V1 01-01-19

ALUNBRIG 2019 PA FAX 1816-A V1 01-01-19

AMPYRA 2019 PA FAX 477-A V1 01-01-19

ANADROL 2019 PA FAX 1495-A V1 01-01-19

ANTIEMETICS 2019 PA FAX BD-16 V1 01-01-19

APOKYN 2019 PA FAX 22-A V1 01-01-19

ARCALYST 2019 PA FAX 597-A V1 01-01-19

AURYXIA 2019 PA FAX 2717-A V1 01-01-19

AUSTEDO 2019 PA FAX 1748-A V1 01-01-19

AVASTIN BDCLIN 2019 PA FAX 799-A BD-13 V1 01-01-19

BANZEL 2019 PA FAX 1386-A V1 01-01-19

BENLYSTA 2019 PA FAX 862-A V1 01-01-19

BERINERT 2019 PA FAX 860-A V1 01-01-19

BETASERON EXTAVIA 2019 PA FAX 543-A V1 01-01-19

BRAFTOVI 2019 PA FAX 2615-A V1 01-01-19

BUPHENYL 2019 PA FAX 965-A V1 01-01-19

BUPRENORPHINE 2019 PA FAX 1391-A V1 01-01-19

CABOMETYX 2019 PA FAX 1367-A V1 01-01-19

CALQUENCE 2019 PA Fax 2398-A V1 01-01-19

CAPRELSA 2019 PA FAX 801-A V1 01-01-19

CARBAGLU 2019 PA FAX 840-A V1 01-01-19

CAYSTON 2019 PA FAX 480-A V1 01-01-19

CERDELGA 2019 PA FAX 1188-A V1 01-01-19

CEREZYME 2019 PA FAX 1497-A V1 01-01-19

CHANTIX 2019 PA FAX 1393-A V1 01-01-19

CLOMIPRAMINE 2019 PA FAX 2484-A V1 01-01-19

COMETRIQ 2019 PA FAX 916-A V1 01-01-19

COPAXONE GLATOPA 2019 PA FAX 544-A V1 01-01-19

COTELLIC 2019 PA FAX 1307-A V1 01-01-19

CYSTAGON 2019 PA FAX 803-A V1 01-01-19

CYSTARAN 2019 PA FAX 926-A V1 01-01-19

DEMSER 2019 PA FAX 2531-A V1 01-01-19

DURAGESIC 2019 PA FAX 1398-A V1 01-01-19

EMEND VARUBI 2019 PA FAX BD-3 V1 01-01-19

EMSAM 2019 PA FAX 1401-A V1 01-01-19

ENDARI 2019 PA FAX 2211-A V1 01-01-19

EPCLUSA 2019 PA FAX 1508-A V2 01-01-19

EPOGEN PROCRIT 2019 PA FAX 81-A V2 01-01-19

ERIVEDGE 2019 PA FAX 762-A V1 01-01-19

ERLEADA 2019 PA FAX 2499-A V1 01-01-19

ESBRIET 2019 PA FAX 1217-A V2 01-01-19

EXJADE JADENU 2019 PA FAX 553-A V1 01-01-19

FABRAZYME 2019 PA FAX 576-A V1 01-01-19

FARYDAK 2019 PA FAX 1247-A V1 01-01-19

FAZACLO 2019 PA FAX 1403-A V1 01-01-19

FETZIMA 2019 PA FAX 1404-A V1 01-01-19

FIRAZYR 2019 PA FAX 809-A V1 01-01-19

FORTEO 2019 PA FAX 94-A V1 01-01-19

FYCOMPA 2019 PA FAX 1406-A V2 01-01-19

GATTEX 2019 PA FAX 938-A V1 01-01-19

GILENYA 2019 PA FAX 620-A V1 01-01-19

GILOTRIF 2019 PA FAX 1011-A V1 01-01-19

GRALISE 2019 PA FAX 2535-A V1 01-01-19

GRANIX 2019 PA FAX 2620-A V1 01-01-19

GROWTH HORMONE 2019 PA FAX 101-A V1 01-01-19

HAEGARDA 2019 PA FAX 2101-A V1 01-01-19

HARVONI 2019 PA FAX 1209G_A V2 01-01-19

HEPATITIS B 2019 PA FAX BD-5 V1 01-01-19

HERCEPTIN BDCLIN 2019 PA FAX 1499-A BD-13 V1 01-01-19

HETLIOZ 2019 PA FAX 1125-A V1 01-01-19

HRM ANTIPARKINSON 2019 PA FAX 1416-A V1 01-01-19

HRM HYDROXYZINE 2019 PA FAX 1414-A V1 01-01-19

HRM HYDROXYZINE INJ 2019 PA FAX 1415-A V1 01-01-19

HRM HYPNOTICS 2019 PA FAX 1421-A V1 01-01-19

HRM LOW IMPACT 2019 PA FAX 1422-A V1 01-01-19

HRM NITROFURANTOIN 2019 PA FAX 1419-A V1 01-01-19

HRM PROMETHAZINE 2019 PA FAX 1413-A V1 01-01-19

HRM SKELETAL MUSCLE RELAXANTS 2019 PA FAX 1420-A V1 01-01-19

HUMIRA 2019 PA FAX 107-A V1 01-01-19

HYPNOTIC BENZODIAZEPINES 2019 PA FAX 1427-B V1 01-01-19

IBRANCE 2019 PA FAX 1236-A V1 01-01-19

ICLUSIG 2019 PA FAX 920-A V1 01-01-19

IDHIFA 2019 PA FAX 2239-A V1 01-01-19

IMBRUVICA 2019 PA FAX 1050-A V1 01-01-19

IMMUNOSUPPRESSANTS 2019 PA FAX BD-6 V1 01-01-19

INCRELEX 2019 PA FAX 551-A V1 01-01-19

INFUSION 2019 PA FAX BD-20 V2 01-01-19

INH BETA2 ANTICHOL CORTICO MAST 2019 PA FAX BD-8 V2 01-01-19

INH MUCOLYTICS 2019 PA FAX BD-10 V2 01-01-19

INH PENTAMIDINE 2019 PA FAX BD-11 V2 01-01-19

INJECTABLE 2019 PA FAX BD-13 V1 01-01-19

INLYTA 2019 PA FAX 747-A V1 01-01-19

IRESSA 2019 PA FAX 1282-A V1 01-01-19

ISOTRETINOIN 2019 PA FAX 1430-A V1 01-01-19

IVIG BDCLIN 2019 PA FAX 119-A BD-15 V1 01-01-19

JAKAFI 2019 PA FAX 723-A V1 01-01-19

JUXTAPID 2019 PA FAX 925-A V1 01-01-19

KALYDECO 2019 PA FAX 753-A V2 01-01-19

KEYTRUDA 2019 PA FAX 1185-A V1 01-01-19

KISQALI 2019 PA FAX 1638-A V2 01-01-19

KORLYM 2019 PA FAX 778-A V1 01-01-19

KUVAN 2019 PA FAX 341-A V1 01-01-19

KYNAMRO 2019 PA FAX 937-A V1 01-01-19

LENVIMA 2019 PA FAX 1248-A V2 01-01-19

LETAIRIS 2019 PA FAX 640-A V1 01-01-19

LIDODERM 2019 PA FAX 1433-A V1 01-01-19

LONSURF 2019 PA FAX 1298-A V1 01-01-19

LOTRONEX 2019 PA FAX 1435-A V1 01-01-19

LUMIZYME 2019 PA FAX 593-A V1 01-01-19

LUPRON ENDOMETRIOSIS 2019 PA FAX 567-A V1 01-01-19

LUPRON PROSTATE 2019 PA FAX 347-A V1 01-01-19

LUPRON PUBERTY 2019 PA FAX 549-A V1 01-01-19

LYNPARZA 2019 PA FAX 1232-A V1 01-01-19

LYRICA CR 2019 PA FAX 2537-A V1 01-01-19

MAVYRET 2019 PA FAX 2243-A V2 01-01-19

MEGACE ES 2019 PA FAX 1437-A V1 01-01-19

MEKINIST 2019 PA FAX 999-A V1 01-01-19

MEKTOVI 2019 PA FAX 2613-A V1 01-01-19

MYLOTARG 2019 PA FAX 2303-A V1 01-01-19

NAGLAZYME 2019 PA FAX 577-A V1 01-01-19

NAMENDA 2019 PA FAX 1439-B V1 01-01-19

NATPARA 2019 PA FAX 1263-A V1 01-01-19

NERLYNX 2019 PA FAX 2180-A V1 01-01-19

NEUPOGEN ZARXIO 2019 PA FAX 154-A V1 01-01-19

NEXAVAR 2019 PA FAX 417-A V1 01-01-19

NINLARO 2019 PA FAX 1312-A V1 01-01-19

NIZORAL 2019 PA FAX 1440-A V1 01-01-19

NORTHERA 2019 PA FAX 1142-A V1 01-01-19

NUEDEXTA 2019 PA FAX 1441-A V1 01-01-19

NUPLAZID 2019 PA FAX 1366-A V1 01-01-19

NUVIGIL 2019 PA FAX 1442-A V1 01-01-19

OCTREOTIDE SANDOSTATIN 2019 PA FAX 1183-A V1 01-01-19

ODOMZO 2019 PA FAX 1283-A V1 01-01-19

ONFI 2019 PA FAX 1443-A V1 01-01-19

OPIOIDS ER 2019 PA FAX 2493-A V1 01-01-19

OPSUMIT 2019 PA FAX 1049-A V1 01-01-19

ORAL CHEMO 2019 PA FAX BD-17 V1 01-01-19

ORAL INTRANASAL FENTANYL 2019 PA FAX 1445-A V1 01-01-19

ORFADIN 2019 PA FAX 579-A V1 01-01-19

OXANDRIN 2019 PA FAX 1384-A V1 01-01-19

PARENTERAL NUTRITION 2019 PA FAX BD-18 V2 01-01-19

PEGASYS 2019 PA FAX 556-A V1 01-01-19

POMALYST 2019 PA FAX 963-A V1 01-01-19

PRISTIQ 2019 PA FAX 2485-A V1 01-01-19

PROMACTA 2019 PA FAX 592-A V1 01-01-19

PROVIGIL 2019 PA FAX 1450-A V1 01-01-19

PULMOZYME BDCLIN 2019 PA FAX 563-A BD-10 V1 01-01-19

QUALAQUIN 2019 PA FAX 1451-A V1 01-01-19

RABIES VACCINE 2019 PA FAX BD-23 V1 01-01-19

REGRANEX 2019 PA FAX 1453-A V1 01-01-19

RELISTOR INJ 2019 PA FAX 1454-A V1 01-01-19

REMICADE INFLECTRA RENFLEXIS 2019 PA FAX 187-A V1 01-01-19

REMODULIN BDCLIN 2019 PA FAX 188-A BD-20 V1 01-01-19

REVLIMID 2019 PA FAX 386-A V1 01-01-19

RITUXAN 2019 PA FAX 194-A V2 01-01-19

RITUXAN HYCELA 2019 PA FAX 2106-A V1 01-01-19

RUBRACA 2019 PA FAX 1569-A V1 01-01-19

RYDAPT 2019 PA FAX 1818-A V1 01-01-19

SABRIL 2019 PA FAX 548-A V1 01-01-19

SIGNIFOR 2019 PA FAX 970-A V1 01-01-19

SILDENAFIL REVATIO ORAL 2019 PA FAX 641-A V1 01-01-19

SIRTURO 2019 PA FAX 1456-A V1 01-01-19

SOMATULINE DEPOT 2019 PA FAX 671-A V1 01-01-19

SOMAVERT 2019 PA FAX 564-A V1 01-01-19

SORIATANE 2019 PA FAX 1459-A V1 01-01-19

SPORANOX 2019 PA FAX 1432-A V1 01-01-19

SPRYCEL 2019 PA FAX 422-A V1 01-01-19

STIVARGA 2019 PA FAX 820-A V1 01-01-19

SUTENT 2019 PA FAX 418-A V1 01-01-19

SYLATRON 2019 PA FAX 660-A V1 01-01-19

SYMDEKO 2019 PA FAX 2515-A V1 01-01-19

SYNRIBO 2019 PA FAX 886-A V1 01-01-19

SYPRINE 2019 PA FAX 2486-A V1 01-01-19

TAFINLAR 2019 PA FAX 1000-A V1 01-01-19

TAGRISSO 2019 PA FAX 1305-A V1 01-01-19

TARCEVA 2019 PA FAX 223-A V1 01-01-19

TARGRETIN 2019 PA FAX 507-A V1 01-01-19

TASIGNA 2019 PA FAX 421-A V1 01-01-19

TAZORAC 2019 PA FAX 1462-A V1 01-01-19

TECENTRIQ 2019 PA FAX 1374-A V1 01-01-19

TESTOSTERONE CYPIONATE INJ 2019 PA FAX 1464-A V1 01-01-19

TESTOSTERONE ENANTHATE INJ 2019 PA FAX 1463-A V1 01-01-19

TETANUS VACCINE 2019 PA FAX BD-19 V1 01-01-19

THALOMID 2019 PA FAX 230-A V1 01-01-19

TIBSOVO 2019 PA FAX 2637-A V1 01-01-19

TOBRAMYCIN BDCLIN 2019 PA FAX 232-A BD-12 V1 01-01-19

TOPICAL LIDOCAINE 2019 PA FAX 1434-A V1 01-01-19

TOPICAL TESTOSTERONES 2019 PA FAX 1465-A V1 01-01-19

TOPICAL TRETINOIN 2019 PA FAX 1467-A V2 01-01-19

TRACLEER 2019 PA FAX 234-A V1 01-01-19

TRANXENE T 2019 PA FAX 1466-B V1 01-01-19

TRELSTAR 2019 PA FAX 283-A V1 01-01-19

TYKERB 2019 PA FAX 308-A V1 01-01-19

TYMLOS 2019 PA FAX 1827-A V1 01-01-19

VALCHLOR 2019 PA FAX 1044-A V1 01-01-19

VALIUM 2019 PA FAX 1473-B V1 01-01-19

VELCADE BDCLIN 2019 PA FAX 763-A BD-13 V1 01-01-19

VENCLEXTA 2019 PA FAX 1353-A V1 01-01-19

VENTAVIS BDCLIN 2019 PA FAX 240-A BD-9 V1 01-01-19

VERSACLOZ 2019 PA FAX 1474-A V1 01-01-19

VERZENIO 2019 PA FAX 2343-A V1 01-01-19

VITAMIN D TOPICAL 2019 PA FAX 2569-A V1 01-01-19

VOLTAREN GEL 2019 PA FAX 1479-A V1 01-01-19

VOSEVI 2019 PA FAX 2177-A V2 01-01-19

VOTRIENT 2019 PA FAX 547-A V1 01-01-19

VRAYLAR 2019 PA FAX 1592-A V1 01-01-19

XALKORI 2019 PA FAX 697-A V1 01-01-19

XELJANZ 2019 PA FAX 914-A V2 01-01-19

XENAZINE 2019 PA FAX 360-A V1 01-01-19

XGEVA BDCLIN 2019 PA FAX 637-A BD-13 V1 01-01-19

XIFAXAN 2019 PA FAX 1480-A V1 01-01-19

XOLAIR 2019 PA FAX 473-A V1 01-01-19

XTANDI 2019 PA FAX 816-A V1 01-01-19

XYREM 2019 PA FAX 1481-A V1 01-01-19

ZAVESCA 2019 PA FAX 580-A V1 01-01-19

ZEJULA 2019 PA FAX 1689-A V1 01-01-19

ZELBORAF 2019 PA FAX 696-A V1 01-01-19

ZEPATIER 2019 PA FAX 1336-A V1 01-01-19

ZOLINZA 2019 PA FAX 566-A V1 01-01-19

ZYDELIG 2019 PA FAX 1174-A V1 01-01-19

ZYKADIA 2019 PA FAX 1136-A V1 01-01-19

ZYPREXA RELPREVV 2019 PA FAX 1483-A V1 01-01-19

ZYTIGA 2019 PA FAX 661-A V1 01-01-19

 

 

 

Updated 01/2019