Fee-for-Service Pharmacy Prior Authorization Fax Forms

NOTE: Please use the Non-Preferred Medication Form for drugs included on the Statewide PDL that do not have a corresponding drug-specific or PDL class-specific form in the list below. 

• Acne Agents, Oral Form
  
• Acne Agents, Topical Form
  
• Analgesics, Non-Opioid Barbiturate Combinations Form
• Analgesics, Opioids Long-Acting Form
  
• Analgesics, Opioids Short-Acting Form
  
• Androgenic Agents Form
  
• Antibiotics, GI and Related Agents Form
• Antidepressants, Other
• Antifibrotic Respiratory Agents
  
• Antihemophilia Agents Form
  
• Antihyperuricemics - Krystexxa Form
  
• Antipsychotics Form
  
• Antivirals, CMV Form
  
• Benzodiazepines Form
  
• Bile Salts - Cholbam and Ocaliva Form
  
• Blood Glucose Meters and Test Strips Form
• Bone Density Regulators Form
• Botulinum Toxins Form
  
• Colony Stimulating Factors Form
• Continuous Glucose Monitoring Products Form
• COPD Agents - Daliresp Form
• Cytokine and CAM Antagonists Form
  
• Dupixent Form
  
• Enzyme Replacements, Gaucher Disease Form
• Erythropoiesis Stimulating Agents Form
  
• Estrogens Form
  
• GI Motility, Chronic
  
• Growth Hormones Form
  
• Hepatitis C Agents Form
• Hereditary Angioedema Agents Form
• Hypoglycemics, Incretin Mimetics-Enhancers Form
• Immunomodulators, Atopic Dermatitis
• Immunosuppressives, Oral - Lupkynis Form
  
• Intra-Articular Hyaluronates Form
• Iron Chelating Agents Form
  
• Lipotropics, Other Form
  
• Macular Degeneration Agents Form
  
• Migraine Acute Treatment Agents Form
  
• Migraine Prevention Agents Form
  
• Monoclonal Antibodies - Anti-IL, Anti-IgE, Anti-TSLP Form
  
• Multiple Sclerosis Form
  
• Natalizumb Form
• NSAIDs - Ketorolac Form
  
• Obesity Treatment Agents Form
• Oncology Agents, Oral Form
• Opioid Use Disorder Treatments Form
  
• Pituitary Suppressive Agents, LHRH Form
  
• Potassium Removing Agents Form
  
• Proton Pump Inhibitors < 6 Years of Age Form
• Pulmonary Hypertension Agents, Oral and Inhaled Form
  
• Sickle Cell Anemia Agents Form
• Stimulants and Related Agents Form
• Stimulants and Related Agents - Provigil, Nuvigil, Sunosi, and Wakix Form
• Thalidomide and Derivatives Form
• Thrombopoietics Form
• Ulcerative Colitis Agents Form
• Urea Cycle Disorder Agents Form
  
• VMAT2 Inhibitors Form

• Abecma Form
  
• Adstiladrin Form
  
• Alpha-1 Proteinase Inhibitors Form (Aralast-NP, Glassia, Prolastin-C, Zemaira)
• Amvuttra Form
  
• Amyloid-Targeted Monoclonal Antibodies (MABs) Form (Aduhelm, Leqembi)
  
• Benlysta Form
  
• Brand Medically Necessary Form
• Breyanzi Form
• Brineura Form
• Camzyos Form
• Carvykti Form
  
• CFTR Modulators Form (Kalydeco, Orkambi, Symdeko, Trikafta)
  
• Complement Inhibitors Form (Empaveli, Enjaymo, Fabhalta, Solitis, Tavneos, Ultomiris, Veopaz, Vodeya, Zilbrysq)
  
• Compounded Prescriptions Form
• Corlanor Form
• Corticotropin Form
• Cough and Cold Medications Form
  
• Crysvita Form
• Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides Form (Amondys-45, Exondys 51, Viltepso, Vyondys 53)
• Elevidys Form
• Elitek Form
• Evrysdi Form
• Filspari Form
• Filsuvez Form
• Hyftor Form
• Imcivree Form
• Immune Globulins Form
• Iqirvo Form
• Joenja Form
• Jynarque Form
• Kanuma Form
• Korlym Form
• Kuvan Form
• Kymriah Form
• Mozobil Form
• Nuedexta Form
• Omisirge Form
• Onpattro Form
• Palforzia Form
• Palynziq Form
• Provenge Form
• Quantity Limits/Daily Dose Limits Form
• Radicava Form
• Rezdiffra Form
• Roctavian Form
• Skyclarys Form
  
• Skysona Form
• Spinraza Form
• Synagis Form
• Tecartus Form
• Tegsedi Form
• Tepezza Form
• Therapeutic Duplication Form
• Tzield Form
• Uplizna Form
• Vecamyl Form
• Veozah Form
• Vijoice Form
• Vuity Form
• Vyjuvek Form
• Vyndamax Form
• Vyndaqel Form
• Vyvgart Form
• Wainua Form
• Xermelo Form
• Xofigo Form
• Xyrem and Xywav Form
• Yescarta Form
• Zolgensma Form
• Zulresso Form
• Zurzuvae Form
• Zynteglo Form