2020 Prior Authorization Forms

 

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

 

Actimmune 2020 PA Fax 562-A V1 01-01-20

Adempas 2020 PA Fax 1048-A V1 01-01-20

Aimovig 2020 PA Fax 3193-A V1 01-01-20

Aldurazyme 2020 PA Fax 573-A V1 01-01-20

Alecensa 2020 PA Fax 1322-A V1 01-01-20

Alpha-1 Proteinase Inhibitors 2020 PA Fax 11-A V1 01-01-20

Alunbrig 2020 PA Fax 1816-A V1 01-01-20

Ampyra 2020 PA Fax 477-A V1 01-01-20

Anadrol 2020 PA Fax 1495-A V1 01-01-20

Antiemetics 2020 PA Fax BD-16 V1 01-01-20

Apokyn 2020 PA Fax 22-A V1 01-01-20

Arcalyst 2020 PA Fax 597-A V1 01-01-20

Atypical Antipsychotics 2020 PA Fax 1385-A V1 01-01-20

Auryxia 2020 PA Fax 2717-A V1 01-01-20

Austedo 2020 PA Fax 1748-A V1 01-01-20

Avastin BDC 2020 PA Fax 799-A BD-13 V1 01-01-20

Balversa 2020 PA Fax 2966-A V1 01-01-20

Banzel 2020 PA Fax 1386-A V1 01-01-20

Benlysta 2020 PA Fax 862-A V1 01-01-20

Berinert 2020 PA Fax 860-A V1 01-01-20

Betaseron Extavia 2020 PA Fax 543-A V1 01-01-20

Bosulif 2020 PA Fax 806-A V1 01-01-20

Braftovi 2020 PA Fax 2615-A V1 01-01-20

Briviact 2020 PA Fax 1500-A V1 01-01-20

Buphenyl 2020 PA Fax 965-A V1 01-01-20

Buprenorphine 2020 PA Fax 1391-A V1 01-01-20

Cabometyx 2020 PA Fax 1367-A V1 01-01-20

Calquence 2020 PA Fax 2398-A V1 01-01-20

Caprelsa 2020 PA Fax 801-A V1 01-01-20

Cayston 2020 PA Fax 480-A V1 01-01-20

Cerdelga 2020 PA Fax 1188-A V1 01-01-20

Cerezyme 2020 PA Fax 1497-A V1 01-01-20

Chantix 2020 PA Fax 1393-A V1 01-01-20

Clomipramine 2020 PA Fax 2484-A V1 01-01-20

Cometriq 2020 PA Fax 916-A V1 01-01-20

Copaxone Glatopa 2020 PA Fax 544-A V1 01-01-20

Cotellic 2020 PA Fax 1307-A V1 01-01-20

Cystagon 2020 PA Fax 803-A V1 01-01-20

Cystaran 2020 PA Fax 926-A V1 01-01-20

Daurismo 2020 PA Fax 2794-A V1 01-01-20

Demser 2020 PA Fax 2531-A V1 01-01-20

Desvenlafaxine ER 2020 PA Fax 2485-A V1 01-01-20

Emend Varubi 2020 PA Fax BD-3 V1 01-01-20

Emsam 2020 PA Fax 1401-A V1 01-01-20

Endari 2020 PA Fax 2211-A V1 01-01-20

Epclusa 2020 PA Fax 1508-A V1 01-01-20

Epidiolex 2020 PA Fax 2608-A V1 01-01-20

Erivedge 2020 PA Fax 762-A V1 01-01-20

Erleada 2020 PA Fax 2499-A V2 01-01-20

Esbriet 2020 PA Fax 1217-A V1 01-01-20

ESRD 2020 PA Fax 1039-A V2 01-01-20

Exjade Jadenu 2020 PA Fax 553-A V1 01-01-20

Fabrazyme 2020 PA Fax 576-A V1 01-01-20

Farydak 2020 PA Fax 1247-A V1 01-01-20

Fazaclo 2020 PA Fax 1403-A V1 01-01-20

Fentanyl Patch 2020 PA Fax 1398-A V1 01-01-20

Fetzima 2020 PA Fax 1404-A V1 01-01-20

Firazyr 2020 PA Fax 809-A V1 01-01-20

Forteo 2020 PA Fax 94-A V1 01-01-20

Fycompa 2020 PA Fax 1406-A V1 01-01-20

Gattex 2020 PA Fax 938-A V1 01-01-20

Gilenya 2020 PA Fax 620-A V2 01-01-20

Gilotrif 2020 PA Fax 1011-A V1 01-01-20

Gleevec 2020 PA Fax 99-A V1 01-01-20

Gralise 2020 PA Fax 2535-A V1 01-01-20

Growth Hormone 2020 PA Fax 101-A V1 01-01-20

Haegarda 2020 PA Fax 2101-A V1 01-01-20

Harvoni 2020 PA Fax 1209-A V1 01-01-20

Hepatitis B 2020 PA Fax BD-5 V1 01-01-20

Herceptin BDC 2020 PA Fax 1499-A BD-13 V1 01-01-20

Hetlioz 2020 PA Fax 1125-A V1 01-01-20

Hospice 2020 PA Fax 1041-A V1 01-01-20

HRM Anticonvulsants 2020 PA Fax 1410-A V1 01-01-20

HRM Antiparkinson Agents 2020 PA Fax 1416-A V1 01-01-20

HRM Hydroxyzine 2020 PA Fax 1414-A V2 01-01-20

HRM Hydroxyzine Inj 2020 PA Fax 1415-A V1 01-01-20

HRM Hypnotics 2020 PA Fax 1421-A V1 01-01-20

HRM Low Impact 2020 PA Fax 1422-A V1 01-01-20

HRM Promethazine 2020 PA Fax 1413-A V1 01-01-20

HRM Skeletal Mscle Relxnts 2020 PA Fax 1420-A V1 01-01-20

Humira 2020 PA Fax 107-A V1 01-01-20

Hypnotics Benzodiazepines 2020 PA Fax 1427-B V1 01-01-20

Ibrance 2020 PA Fax 1236-A V1 01-01-20

Iclusig 2020 PA Fax 920-A V1 01-01-20

Idhifa 2020 PA Fax 2239-A V1 01-01-20

Imbruvica 2020 PA Fax 1050-A V1 01-01-20

Increlex 2020 PA Fax 551-A V1 01-01-20

Infliximab 2020 PA Fax 187-A V1 01-01-20

Infusion 2020 PA Fax BD-20 V1 01-01-20

Inh BetaAg Antich Cort Mast 2020 PA Fax BD-8 V1 01-01-20

Inh Mucolytics 2020 PA Fax BD-10 V1 01-01-20

Inh Pentamidine 2020 PA Fax BD-11 V1 01-01-20

Injectables 2020 PA Fax BD-13 V1 01-01-20

Inlyta 2020 PA Fax 747-A V1 01-01-20

Inrebic 2020 PA Fax 3162-A V1 01-01-20

Iressa 2020 PA Fax 1282-A V1 01-01-20

Isotretinoin 2020 PA Fax 1430-A V1 01-01-20

Juxtapid 2020 PA Fax 925-A V1 01-01-20

Kalydeco 2020 PA Fax 753-A V1 01-01-20

Keytruda 2020 PA Fax 1185-A V2 01-01-20

Kisqali Femara 2020 PA Fax 1638-A V1 01-01-20

Korlym 2020 PA Fax 778-A V1 01-01-20

Kuvan 2020 PA Fax 341-A V1 01-01-20

Lenvima 2020 PA Fax 1248-A V2 01-01-20

Letairis 2020 PA Fax 640-A V1 01-01-20

Lidoderm 2020 PA Fax 1433-A V1 01-01-20

Lonsurf 2020 PA Fax 1298-A V1 01-01-20

Lorbrena 2020 PA Fax 2788-A V1 01-01-20

Lotronex 2020 PA Fax 1435-A V1 01-01-20

Lumizyme 2020 PA Fax 593-A V1 01-01-20

Lupron Endometriosis 2020 PA Fax 567-A V1 01-01-20

Lupron Prostate 2020 PA Fax 347-A V1 01-01-20

Lupron Puberty 2020 PA Fax 549-A V1 01-01-20

Lynparza 2020 PA Fax 1232-A V1 01-01-20

Lyrica 2020 PA Fax 2898-A V1 01-01-20

Lyrica CR 2020 PA Fax 2537-A V1 01-01-20

Mavyret 2020 PA Fax 2243-A V2 01-01-20

Megace ES 2020 PA Fax 1437-A V1 01-01-20

Mekinist 2020 PA Fax 999-A V1 01-01-20

Mektovi 2020 PA Fax 2613-A V1 01-01-20

Migranal NS 2020 PA Fax 2895-A V1 01-01-20

Naglazyme 2020 PA Fax 577-A V1 01-01-20

Namenda 2020 PA Fax 1439-B V1 01-01-20

Natpara 2020 PA Fax 1263-A V1 01-01-20

Nerlynx 2020 PA Fax 2180-A V1 01-01-20

Nexavar 2020 PA Fax 417-A V1 01-01-20

Ninlaro 2020 PA Fax 1312-A V1 01-01-20

Nizoral 2020 PA Fax 1440-A V1 01-01-20

Northera 2020 PA Fax 1142-A V1 01-01-20

Nubeqa 2020 PA Fax 3149-A V1 01-01-20

Nucala 2020 PA Fax 1302-A V2 01-01-20

Nuedexta 2020 PA Fax 1441-A V1 01-01-20

Nuplazid 2020 PA Fax 1366-A V1 01-01-20

Nuvigil 2020 PA Fax 1442-A V1 01-01-20

Octreotide Sandostatin 2020 PA Fax 1183-A V1 01-01-20

Odomzo 2020 PA Fax 1283-A V1 01-01-20

Ofev 2020 PA Fax 1216-A V2 01-01-20

Onfi Sympazan 2020 PA Fax 1443-A V1 01-01-20

Opioids ER 2020 PA Fax 2493-A V1 01-01-20

Opsumit 2020 PA Fax 1049-A V1 01-01-20

Oral Chemo 2020 PA Fax BD-17 V1 01-01-20

Oral Intranasal Fentanyl 2020 PA Fax 1445-A V1 01-01-20

Orfadin Nityr 2020 PA Fax 579-A V1 01-01-20

Orkambi 2020 PA Fax 1279-A V1 01-01-20

Oxandrin 2020 PA Fax 1384-A V1 01-01-20

Parenteral Nutrition 2020 PA Fax BD-18 V1 01-01-20

Pegasys 2020 PA Fax 556-A V1 01-01-20

Piqray 2020 PA Fax 3090-A V1 01-01-20

Pomalyst 2020 PA Fax 963-A V1 01-01-20

Praluent 2020 PA Fax 1280-A V1 01-01-20

Promacta 2020 PA Fax 592-A V1 01-01-20

Provigil 2020 PA Fax 1450-A V1 01-01-20

Pulmozyme BDC 2020 PA Fax 563-A BD-10 V1 01-01-20

Qualaquin 2020 PA Fax 1451-A V1 01-01-20

Rabies Vaccine 2020 PA Fax BD-23 V1 01-01-20

Regranex Med D 03-2018 1453-A 01-01-20

Relistor Inj 2020 PA Fax 1454-A V1 01-01-20

Remodulin BDC 2020 PA Fax 188-A BD-20 V1 01-01-20

Revatio Oral 2020 PA Fax 641-A V1 01-01-20

Revlimid 2020 PA Fax 386-A V1 01-01-20

Rituxan 2020 PA Fax 194-A V1 01-01-20

Rituxan Hycela 2020 PA Fax 2106-A V1 01-01-20

Rozlytrek 2020 PA Fax 3166-A V1 01-01-20

Rubraca 2020 PA Fax 1569-A V1 01-01-20

Rydapt 2020 PA Fax 1818-A V1 01-01-20

Seroquel XR 2020 PA Fax 2875-A V1 01-01-20

Signifor 2020 PA Fax 970-A V1 01-01-20

Sirturo 2020 PA Fax 1456-A V1 01-01-20

Somatuline Depot 2020 PA Fax 671-A V1 01-01-20

Soriatane 2020 PA Fax 1459-A V1 01-01-20

Sporanox 2020 PA Fax 1432-A V1 01-01-20

Sprycel 2020 PA Fax 422-A V1 01-01-20

Stelara 2020 PA Fax 560-A V1 01-01-20

Stivarga 2020 PA Fax 820-A V1 01-01-20

Sutent 2020 PA Fax 418-A V1 01-01-20

Sylatron 2020 PA Fax 660-A V1 01-01-20

Symdeko 2020 PA Fax 2515-A V1 01-01-20

Synribo 2020 PA Fax 886-A V1 01-01-20

Syprine 2020 PA Fax 2486-A V1 01-01-20

Tafinlar 2020 PA Fax 1000-A V1 01-01-20

Tarceva 2020 PA Fax 223-A V1 01-01-20

Targretin 2020 PA Fax 507-A V1 01-01-20

Tasigna 2020 PA Fax 421-A V1 01-01-20

Tazorac 2020 PA Fax 1462-A V1 01-01-20

Tecentriq 2020 PA Fax 1374-A V1 01-01-20

Testosterone Cypionate 2020 PA Fax 1464-A V1 01-01-20

Testosterone Enanthate 2020 PA Fax 1463-A V1 01-01-20

Tetanus Vaccine 2020 PA Fax BD-19 V1 01-01-20

Thalomid 2020 PA Fax 230-A V1 01-01-20

Tibsovo 2020 PA Fax 2637-A V1 01-01-20

Tobramycin BDC 2020 PA Fax 232-A BD-12 V1 01-01-20

Topical Lidocaine 2020 PA Fax 1434-A V1 01-01-20

Topical Testosterone 2020 PA Fax 1465-A V1 01-01-20

Topical Tretinoins 2020 PA Fax 1467-A V1 01-01-20

Tracleer 2020 PA Fax 234-A V1 01-01-20

Tranxene T 2020 PA Fax 1466-B V1 01-01-20

Trelstar 2020 PA Fax 283-A V1 01-01-20

Trintellix 2020 PA Fax 1468-A V1 01-01-20

Tykerb 2020 PA Fax 308-A V1 01-01-20

Tymlos 2020 PA Fax 1827-A V1 01-01-20

Valchlor 2020 PA Fax 1044-A V1 01-01-20

Valium 2020 PA Fax 1473-B V1 01-01-20

Velcade BDC 2020 PA Fax 763-A BD13 V1

Venclexta 2020 PA Fax 1353-A V1 01-01-20

Ventavis BDC 2020 PA Fax 240-A BD-9 V1

Versacloz 2020 PA Fax 1474-A V1 01-01-20

Verzenio 2020 PA Fax 2343-A V1 01-01-20

Vfend 2020 PA Fax 2877-A V1 01-01-20

Vigabatrin 2020 PA Fax 548-A V1 01-01-20

Viibryd 2020 PA Fax 1477-A V1 01-01-20

Vitamin D Topical 2020 PA Fax 2569-A V1 01-01-20

Vitrakvi 2020 PA Fax 2801-A V1 01-01-20

Vizimpro 2020 PA Fax 2771-A V1 01-01-20

Voltaren Gel 2020 PA Fax 1479-A V1 01-01-20

Vosevi 2020 PA Fax 2177-A V1 01-01-20

Votrient 2020 PA Fax 547-A V1 01-01-20

Vraylar 2020 PA Fax 1592-A V1 01-01-20

Xalkori 2020 PA Fax 697-A V1 01-01-20

Xeljanz 2020 PA Fax 914-A V1 01-01-20

Xenazine 2020 PA Fax 360-A V1 01-01-20

Xgeva BDC 2020 PA Fax 637-A BD-13 V1 01-01-20

Xifaxan 2020 PA Fax 1480-A V1 01-01-20

Xolair 2020 PA Fax 473-A V1 01-01-20

Xospata 2020 PA Fax 2808-A V1 01-01-20

Xpovio 2020 PA Fax 3121-A V1 01-01-20

Xtandi 2020 PA Fax 816-A V1 01-01-20

Xyrem 2020 PA Fax 1481-A V1 01-01-20

Zavesca 2020 PA Fax 580-A V1 01-01-20

Zejula 2020 PA Fax 1689-A V1 01-01-20

Zelboraf 2020 PA Fax 696-A V1 01-01-20

Zolinza 2020 PA Fax 566-A V1 01-01-20

Updated 01/2020