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Prior Authorization Forms

To view and print the form desired, click on the form name.

Acne Agents (PDF)
(Differin, Azelex)

Altace (PDF)

Amitiza (PDF)

Antidepressants Medication (PDF)
(Lexapro, Cymbalta, Effexor Xr, Paxil)

Anti-Inflammatory Medication - Arthrotec (PDF)

Anti-Inflammatory Medication - Celebrex (PDF)

Anti-Rejection Drugs Post Transplant (PDF)
(Medicare Part B Vs. Part D - Azathioprine, Cellcept, Cyclosporine, Myfortic, Neoral, Prograf, Rapamune, Sandimune)

Crestor (PDF)

Epoetin (PDF)
(Medicare Part B Vs. Part D)

Forteo (PDF)

Gardasil (PDF)

Gleevec (PDF)

Hepatitis B Vaccine (PDF)
(Medicare Part B Vs. Part D)

Humira (PDF)
(Crohn's Disease)

Increlex (PDF)

INJECTABLES MEDICATIONS (PDF)
(Medicare Part B Vs. Part D)

Itraconazole (PDF)

IVIG Injectable Medications (PDF)
(Medicare Part B Vs. Part D)

Kuvan (PDF)

Lipitor, Caduet (PDF)

Lyrica (PDF)

Nebulizer (PDF)

Nexavar (PDF)

Norditropin (PDF)

Oral Chemotherapy Agents (PDF)
(Medicare Part B Vs. Part D - Alkeran, Cytoxan, Myleran, Temodar, Trexall, Vepesid, Xeloda)

Oral Fentanyl (PDF)
(Actiq, Fentanyl Citrate Transmucosal, Fentora)

Plaque Psoriasis Initial Approval (PDF)
(Enbrel, Raptiva)

Plaque Psoriasis Continuing Therapy (PDF)
(Enbrel, Raptiva)

PPI's (PDF)
(Prevacid, Nexium, Protonix, Aciphex)

Provigil (PDF)

Regranex (PDF)

Remicade (PDF)

Restasis (PDF)

Revatio (PDF)

Rheumatoid Arthritis (PDF)
(Humira, Kineret, Enbrel)

Rozerem (PDF)

Sprycel (PDF)

Sutent (PDF)

Symlin (PDF)

Synagis (PDF)

Tarceva (PDF)

Tasigna (PDF)

Tykerb (PDF)

Vfend (PDF)

Xolair (PDF)

Zyvox (PDF)

S5954_3232_1107     Last Modified Date: 5/5/2008