Prescription Drug Authorization Forms — Medicaid Plans
Medicaid Pharmacy Special Exception Forms and Information
Compound Drugs Prior Authorization Request Form
PDF, 139 KB
PDF, 139 KB
Maximum Daily Dosage Limit Exception Form
PDF, 165 KB
PDF, 165 KB
Pancreatic Enzyme Utilization Criteria for Cystic Fibrosis Request
PDF, 161 KB
PDF, 161 KB
Pharmacy Benefit Oncology Medications
PDF, 180 KB
PDF, 180 KB
Pharmacy Medical Drug Necessity Request
PDF, 142 KB
PDF, 142 KB
Medical Drug Authorization Changes
Drug Authorization Forms
Abilify Mycite (Non-Preferred)
PDF, 200 KB
PDF, 200 KB
Abrysvo (RSV Vaccine)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 131 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 131 KB
Absorica
PDF, 147 KB
PDF, 147 KB
Actemra SQ (Pharmacy benefit - Non-Preferred)
PDF, 209 KB
PDF, 209 KB
Actimmune SQ (Pharmacy benefit)
PDF, 169 KB
PDF, 169 KB
adefovir dipivoxil (ADV, generic Hepsera)
PDF, 193 KB
PDF, 193 KB
ADHD/Stimulant Medications
(See PA Form for Age Criteria)PDF, 178 KB
(See PA Form for Age Criteria)PDF, 178 KB
Albenza | Emverm
PDF, 189 KB
PDF, 189 KB
Allzital
PDF, 173 KB
PDF, 173 KB
Amjevita | Amjevita Autoinjector
PDF, 213 KB
PDF, 213 KB
Ampyra (Non-Preferred)
PDF, 184 KB
PDF, 184 KB
Anti-Allergen, Orals
(Non-Preferred - Grastek | Odactra | Oralair | Ragwitek)PDF, 156 KB
(Non-Preferred - Grastek | Odactra | Oralair | Ragwitek)PDF, 156 KB
Antibiotics-Inhaled
(PREFERRED- Bethkis 300 mg/4mL (QL, AG) | Kitabis Pak 300mg/5mL (QL, AG) | Tobi Podhaler (QL, AG, SE) | tobramycin inhalation neb solution (QL, AG)) (Non-preferred - Arikayce (QL, PA) | Cayston (QL, AG) | Tobi inhalation neb solution (QL,AG) | tobramycin inhalation (QL, AG) | tobramycin PaK (QL, AG))PDF, 180 KB
(PREFERRED- Bethkis 300 mg/4mL (QL, AG) | Kitabis Pak 300mg/5mL (QL, AG) | Tobi Podhaler (QL, AG, SE) | tobramycin inhalation neb solution (QL, AG)) (Non-preferred - Arikayce (QL, PA) | Cayston (QL, AG) | Tobi inhalation neb solution (QL,AG) | tobramycin inhalation (QL, AG) | tobramycin PaK (QL, AG))PDF, 180 KB
Antidepressants
PDF, 171 KB
PDF, 171 KB
Antiemetic-Antivertigo Drugs
(PREFERRED- Diclegis (doxylamine succinate/ vitamin B6 | ondansetron ODT tab/soln | meclizine | metoclopramide tab/soln | Phenadoz (AG, members over 2 yrs of age) | prochlorperazine tab/syrup | promethazine (AG) (members over 2 yrs of age) | Dronabinol cap | (All Non-Preferred Drugs require PA)
PDF, 167 KB
(PREFERRED- Diclegis (doxylamine succinate/ vitamin B6 | ondansetron ODT tab/soln | meclizine | metoclopramide tab/soln | Phenadoz (AG, members over 2 yrs of age) | prochlorperazine tab/syrup | promethazine (AG) (members over 2 yrs of age) | Dronabinol cap | (All Non-Preferred Drugs require PA)
PDF, 167 KB
Antifungals - Oral (Non-Preferred)
PDF, 151 KB
PDF, 151 KB
Antifungals - Topical (Non-Preferred)
PDF, 163 KB
PDF, 163 KB
Anti-Migraine Drugs
(PREFERRED: Aimovig | Ajovy | Emgality Pen & Syringe (120mg) | Nurtec ODT | Ubrelvy) (Non-Preferred: Emgality Syringe (100mg) | Qulipta | Reyvow | Trudhesa | Zazvzpret)
PDF, 190 KB
(PREFERRED: Aimovig | Ajovy | Emgality Pen & Syringe (120mg) | Nurtec ODT | Ubrelvy) (Non-Preferred: Emgality Syringe (100mg) | Qulipta | Reyvow | Trudhesa | Zazvzpret)
PDF, 190 KB
Antipsychotics for Children (Age 0-17 years)
PDF, 180 KB
PDF, 180 KB
Arcalyst (Non-Preferred)
PDF, 198 KB
PDF, 198 KB
Arikayce
PDF, 214 KB
PDF, 214 KB
Atypical Antipsychotics
(Non-Preferred) (Abilify | Abilify Mycite | aripiprazole ODT/solution | asenapine | Caplyta | clozapine ODT | Clozaril | Fanapt | FazaClo | Geodon | Invega | Latuda | Lybalvi | Nuplazid | paliperidone ER | quetiapine ER | Rexulti | Risperdal | Saphris | Secuado Patch | Seroquel | Seroquel XR | Symbyax | Versacloz | Zyprexa)PDF, 169 KB
(Non-Preferred) (Abilify | Abilify Mycite | aripiprazole ODT/solution | asenapine | Caplyta | clozapine ODT | Clozaril | Fanapt | FazaClo | Geodon | Invega | Latuda | Lybalvi | Nuplazid | paliperidone ER | quetiapine ER | Rexulti | Risperdal | Saphris | Secuado Patch | Seroquel | Seroquel XR | Symbyax | Versacloz | Zyprexa)PDF, 169 KB
Benlysta SQ (Pharmacy benefit)
PDF, 291 KB
PDF, 291 KB
Bimzelx
PDF, 149 KB
PDF, 149 KB
Botox - Other Indications (Pharmacy)
PDF, 200 KB
PDF, 200 KB
Botox Injections-Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS)) (Pharmacy)
PDF, 174 KB
PDF, 174 KB
Botox Injection-Type A (Chronic Migraine Headache Prophylaxis) (Pharmacy)
PDF, 217 KB
PDF, 217 KB
Botox Injection-Type A (Hyperhidrosis) (Pharmacy)
PDF, 194 KB
PDF, 194 KB
Bronchitol
PDF, 157 KB
PDF, 157 KB
Bylvay
PDF, 232 KB
PDF, 232 KB
Camzyos
PDF, 140 KB
PDF, 140 KB
carglumic acid (Carbaglu)
PDF, 201 KB
PDF, 201 KB
Celebrex
Non-Preferred Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)PDF, 142 KB
Non-Preferred Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)PDF, 142 KB
Cephalosporins (Oral)
PDF, 190 KB
PDF, 190 KB
Cialis | tadalafil 2.5mg & 5mg (Non-Preferred)
PDF, 149 KB
PDF, 149 KB
Cibinqo (Non-Preferred)
PDF, 183 KB
PDF, 183 KB
Cimzia SQ (Pharmacy benefit)
PDF, 183 KB
PDF, 183 KB
Continuous Glucose Monitors (CGM)
(PREFERRED: Dexcom G6 | Dexcom G7 | FreeStyle Libre 14 day | FreeStyle Libre 2 | FreeStyle Libre 3) (Non-Preferred: Eversense | Guardian 3 | Guardian 4)
PDF, 172 KB
(PREFERRED: Dexcom G6 | Dexcom G7 | FreeStyle Libre 14 day | FreeStyle Libre 2 | FreeStyle Libre 3) (Non-Preferred: Eversense | Guardian 3 | Guardian 4)
PDF, 172 KB
Corlanor
PDF, 186 KB
PDF, 186 KB
Cosentyx SQ (Pharmacy)
PDF, 212 KB
PDF, 212 KB
Crysvita (Pharmacy)
PDF, 152 KB
PDF, 152 KB
Cuvrior | Syprine | trientine
PDF, 209 KB
PDF, 209 KB
Cystaran | Cystadrops
PDF, 182 KB
PDF, 182 KB
Daliresp (Non-Preferred)
PDF, 156 KB
PDF, 156 KB
Daybue
PDF, 231 KB
PDF, 231 KB
deferasirox (Exjade) | Exjade | Ferriprox | Jadenu
PDF, 210 KB
PDF, 210 KB
dichlorphenamide (Keveyis)
PDF, 162 KB
PDF, 162 KB
dihydroergotamine mesylate (D.H.E. 45) injection | dihydroergotamine mesylate (Migranal) nasal spray.pdf
PDF, 162 KB
PDF, 162 KB
Dojolvi
PDF, 229 KB
PDF, 229 KB
Doptelet
PDF, 205 KB
PDF, 205 KB
droxidopa (Northera)
PDF, 151 KB
PDF, 151 KB
Dupixent
PDF, 213 KB
PDF, 213 KB
Egrifta
PDF, 134 KB
PDF, 134 KB
Emflaza (Non-Preferred)
PDF, 170 KB
PDF, 170 KB
Enspryng - Neuromyelitis Optica Spectrum Disorder (NMOSD) (NON-PREFERRED)
PDF, 139 KB
PDF, 139 KB
Enstilar Foam (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Epidiolex CV (Preferred)
PDF, 190 KB
PDF, 190 KB
ethacrynic acid (Edecrin)
PDF, 147 KB
PDF, 147 KB
Evrysdi
PDF, 184 KB
PDF, 184 KB
Fasenra SQ (Pharmacy)
Fentanyl Orals (Fentora | Lazanda | Subsys)
PDF, 202 KB
PDF, 202 KB
Filspari
PDF, 184 KB
PDF, 184 KB
Fintepla
PDF, 197 KB
PDF, 197 KB
Firdapse
PDF, 175 KB
PDF, 175 KB
Forteo | Tymlos (Non-Preferred)
PDF, 196 KB
PDF, 196 KB
Furoscix
PDF, 155 KB
PDF, 155 KB
Galafold
PDF, 169 KB
PDF, 169 KB
Gastrointestinal (GI) Antibiotics
(PREFERRED-Firvanq | metronidazole tab | vancomycin cap) (Non-Preferred drugs require PA)PDF, 206 KB
(PREFERRED-Firvanq | metronidazole tab | vancomycin cap) (Non-Preferred drugs require PA)PDF, 206 KB
Gastrointestinal (GI) Chronic Motility Drugs
(PREFERRED - Amitiza | Linzess | Movantik) (Non-Preferred - alosetron | Lotronex | Motegrity | Relistor | Symproic | Trulance | Viberzi)
PDF, 205 KB
(PREFERRED - Amitiza | Linzess | Movantik) (Non-Preferred - alosetron | Lotronex | Motegrity | Relistor | Symproic | Trulance | Viberzi)
PDF, 205 KB
Gattex Injection
PDF, 259 KB
PDF, 259 KB
Gaucher Disease Drugs (Substrate Reduction Therapy) (Pharmacy)
(Cerdelga | Miglustat)
PDF, 210 KB
(Cerdelga | Miglustat)
PDF, 210 KB
glycopyrrolate (Cuvposa) oral solution
PDF, 185 KB
PDF, 185 KB
Gocovri ER | Osmolex ER
PDF, 197 KB
PDF, 197 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Pharmacy)
(PREFERRED: Eligard | Lupron Depot | Lupron Depot-Ped | Trelstar | Supplrelin LA | Vantas) (Non-Preferred: Camveci | Eligard (1-month) | Fensolvi | Lupron Depot (1-month) | Lupron Depot-Ped (1-month) | Synarel | Trelstar (1-month) | Triptodur | Zoladex)PDF, 227 KB
(PREFERRED: Eligard | Lupron Depot | Lupron Depot-Ped | Trelstar | Supplrelin LA | Vantas) (Non-Preferred: Camveci | Eligard (1-month) | Fensolvi | Lupron Depot (1-month) | Lupron Depot-Ped (1-month) | Synarel | Trelstar (1-month) | Triptodur | Zoladex)PDF, 227 KB
Graft-Versus-Host Disease (GVHD) Drugs
(Jakafi | Imbruvica)
PDF, 211 KB
(Jakafi | Imbruvica)
PDF, 211 KB
Granulocyte Colony-Stimulating Factors (G-CSFs)(G-CSFs)(GM-CSF) (Pharmacy)
Short-Acting Granulocyte Colony-Stimulating Factors (G-CSFs); Granulocyte-macrophage Colony-Stimulating Factor (GM-CSF); Long-Acting Granulocyte Colony-Stimulating Factors (G-CSFs)
PDF, 194 KB
Short-Acting Granulocyte Colony-Stimulating Factors (G-CSFs); Granulocyte-macrophage Colony-Stimulating Factor (GM-CSF); Long-Acting Granulocyte Colony-Stimulating Factors (G-CSFs)
PDF, 194 KB
Growth Hormone (rhGH)
(PREFERRED - Genotropin | Norditropin FlexPro | Nutropin AQ NuSpin) (Non-Preferred: Humatrope |Omnitrope | Serostim | Sogroya | Zomacton)
PDF, 202 KB
(PREFERRED - Genotropin | Norditropin FlexPro | Nutropin AQ NuSpin) (Non-Preferred: Humatrope |Omnitrope | Serostim | Sogroya | Zomacton)
PDF, 202 KB
Hemangeol (Non-Preferred)
PDF, 149 KB
PDF, 149 KB
Hepatitis-C Antiviral Drugs (Non-Preferred)
(Non-Preferred) (Epclusa | Harvoni | Incivek | interferon | ledipasvir/sofosuvir (generic Harvoni) | Olysio | Pegasys | Sovaldi | Technivie | Viekira Pak | Viekira XR | Vosevi | Zepatier)PDF, 166 KB
(Non-Preferred) (Epclusa | Harvoni | Incivek | interferon | ledipasvir/sofosuvir (generic Harvoni) | Olysio | Pegasys | Sovaldi | Technivie | Viekira Pak | Viekira XR | Vosevi | Zepatier)PDF, 166 KB
Hereditary Angioedema (HAE)
(PREFERRED Drugs with Quantity Limits - Berinert | Cinryze | icatibant | Kalibitor | Sajazir) (Non-Preferred Drugs with Quantity Limits - Firazyr | Haegarda | Orladeyo | Ruconest |Takhzyro)
PDF, 173 KB
(PREFERRED Drugs with Quantity Limits - Berinert | Cinryze | icatibant | Kalibitor | Sajazir) (Non-Preferred Drugs with Quantity Limits - Firazyr | Haegarda | Orladeyo | Ruconest |Takhzyro)
PDF, 173 KB
Hetlioz | tasimelteon (generic Hetlioz)
PDF, 190 KB
PDF, 190 KB
Hyftor
PDF, 164 KB
PDF, 164 KB
icosapent ethyl | Lovaza | Omega-3 acid ethyl esters | Omega-3 OTC | Vascepa
PDF, 176 KB
PDF, 176 KB
Immunomodulators Atopic Dermatitis
(PREFERRED: Adbry | Dupixent | Elidel | Eucrisa | tacrolimus) (Non-Preferred: Cibinqo | Opzelura | pimecrolimus | Protopic)
PDF, 188 KB
(PREFERRED: Adbry | Dupixent | Elidel | Eucrisa | tacrolimus) (Non-Preferred: Cibinqo | Opzelura | pimecrolimus | Protopic)
PDF, 188 KB
Increlex
PDF, 177 KB
PDF, 177 KB
Incretin Mimetic Drugs
(PREFERRED: Byetta | Trulicity | Victoza) (Non-Preferred: Adlyxin | Bydureon Bcise SQ | Mounjaro | Ozempic | Rybelsus | Soliqua | Tanzeum | Xultophy)PDF, 162 KB
(PREFERRED: Byetta | Trulicity | Victoza) (Non-Preferred: Adlyxin | Bydureon Bcise SQ | Mounjaro | Ozempic | Rybelsus | Soliqua | Tanzeum | Xultophy)PDF, 162 KB
Infliximab Category (Pharmacy)
(PREFERRED: Infliximab generic Remicade®) (Non-Preferred: Avsola|Inflectra|Remicade|Renflexis) (Pharmacy)
PDF, 189 KB
(PREFERRED: Infliximab generic Remicade®) (Non-Preferred: Avsola|Inflectra|Remicade|Renflexis) (Pharmacy)
PDF, 189 KB
Inpefa
PDF, 133 KB
PDF, 133 KB
Interstitial Lung Disease Agents (Esbriet | Ofev)
PDF, 206 KB
PDF, 206 KB
Javygtor | sapropterin dihydrochloride (Kuvan)
PDF, 179 KB
PDF, 179 KB
Joenja
PDF, 178 KB
PDF, 178 KB
Juxtapid
PDF, 160 KB
PDF, 160 KB
Jynarque
PDF, 166 KB
PDF, 166 KB
Kalydeco
PDF, 162 KB
PDF, 162 KB
Kerendia
PDF, 176 KB
PDF, 176 KB
Kevzara Injection (Non-Preferred)
PDF, 188 KB
PDF, 188 KB
Kineret (Non-Preferred)
PDF, 145 KB
PDF, 145 KB
Korlym
PDF, 167 KB
PDF, 167 KB
Lampit | benznidazole
PDF, 211 KB
PDF, 211 KB
Libtayo
PDF, 163 KB
PDF, 163 KB
Lipotropics - Other (Non-Preferred)
(Leqvio | Praluent | Repatha)
PDF, 217 KB
(Leqvio | Praluent | Repatha)
PDF, 217 KB
Livmarli
PDF, 179 KB
PDF, 179 KB
Livtencity
PDF, 273 KB
PDF, 273 KB
Lodoco
PDF, 166 KB
PDF, 166 KB
Lucemyra
PDF, 153 KB
PDF, 153 KB
Lupkynis
PDF, 194 KB
PDF, 194 KB
Lyrica Solution (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Macrolides & Ketolides (Oral)
(PREFERRED-azithromycin pack, susp, tab | clarithromycin tab, susp | Eryped 200 susp | E.E.S. 200 susp | erythromycin base cap DR | erythromycin stearate)PDF, 163 KB
(PREFERRED-azithromycin pack, susp, tab | clarithromycin tab, susp | Eryped 200 susp | E.E.S. 200 susp | erythromycin base cap DR | erythromycin stearate)PDF, 163 KB
Methadone
PDF, 202 KB
PDF, 202 KB
mifepristone 300 mg
PDF, 169 KB
PDF, 169 KB
Movement Disorders Medications
(PREFERRED: Austedo | Austedo XR | Austedeo XR titration Pack | Ingrezza | Ingrezza Initiation Pack | tetrabenzaine (generic Xenazine) | Xenazine) (Non-Prefered: Austedo XR titration pack)
PDF, 166 KB
(PREFERRED: Austedo | Austedo XR | Austedeo XR titration Pack | Ingrezza | Ingrezza Initiation Pack | tetrabenzaine (generic Xenazine) | Xenazine) (Non-Prefered: Austedo XR titration pack)
PDF, 166 KB
Mulpleta
PDF, 166 KB
PDF, 166 KB
Multiple Sclerosis Drugs (Non-Preferred)
(Non-Preferred - Mavenclad | Mayzent | Ponvory | Zeposia)PDF, 217 KB
(Non-Preferred - Mavenclad | Mayzent | Ponvory | Zeposia)PDF, 217 KB
Multiple Sclerosis Drugs (Preferred)
(PREFERRED - Aubagio | Avonex | Avonex Adm Pack | Betaseron | Copaxone (20mg syringe) | dalfampridine ER (generic Ampyra) | dimethyl fumarate (generic Tecfidera) | fingolimod | Kesimpta) (Non-Preferred - Ampyra | Bafiertam | Copaxone (40mg syringe) | Extavia Kit | Gilenya | glatiramer 20mg syringe |Glatopa | Mavenclad | Mayzent | Plegridy | Rebif SQ | Rebif Redidose Pen | Rebif SQ | Tascenso | Tecfidera | teriflunomide | Vumerity | Zeposia | Zinbryta)
PDF, 170 KB
(PREFERRED - Aubagio | Avonex | Avonex Adm Pack | Betaseron | Copaxone (20mg syringe) | dalfampridine ER (generic Ampyra) | dimethyl fumarate (generic Tecfidera) | fingolimod | Kesimpta) (Non-Preferred - Ampyra | Bafiertam | Copaxone (40mg syringe) | Extavia Kit | Gilenya | glatiramer 20mg syringe |Glatopa | Mavenclad | Mayzent | Plegridy | Rebif SQ | Rebif Redidose Pen | Rebif SQ | Tascenso | Tecfidera | teriflunomide | Vumerity | Zeposia | Zinbryta)
PDF, 170 KB
Myalept
PDF, 178 KB
PDF, 178 KB
Myfembree | Oriahnn
PDF, 171 KB
PDF, 171 KB
Mytesi (formerly Fulyzaq)
PDF, 154 KB
PDF, 154 KB
Narcolepsy Medications
(Non-Preferred) armodafinil | modafinil | Nuvigil | Provigil | Sunosi | Wakix
PDF, 138 KB
(Non-Preferred) armodafinil | modafinil | Nuvigil | Provigil | Sunosi | Wakix
PDF, 138 KB
Nayzilam
PDF, 151 KB
PDF, 151 KB
Nexletol | Nexlizet (Non-Preferred)
PDF, 187 KB
PDF, 187 KB
Nocdurna sublingual tablets
PDF, 160 KB
PDF, 160 KB
Nucala - Chronic Rhinosinusitis with Nasal Polyps (CRSWNP) (Pharmacy)
PDF, 191 KB
PDF, 191 KB
Nucala - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Pharmacy)
PDF, 223 KB
PDF, 223 KB
Nucala - Hypereosinophilic Syndome (HES) (Pharmacy)
PDF, 212 KB
PDF, 212 KB
Nucala - Severe Eosinophilic Asthma (SEA) (Pharmacy)
PDF, 210 KB
PDF, 210 KB
Nuedexta
PDF, 134 KB
PDF, 134 KB
Nulibry IV (Pharmacy)
PDF, 238 KB
PDF, 238 KB
Olumiant
PDF, 165 KB
PDF, 165 KB
Opfolda
PDF, 203 KB
PDF, 203 KB
Ophthalmic Immunomodulator Drugs
(PREFERRED: Restasis | Xiidra) (Non-Preferred: Cequa | Eysuvis | cyclosporine | Miebo | Tyrvaya | Verkazia)
PDF, 166 KB
(PREFERRED: Restasis | Xiidra) (Non-Preferred: Cequa | Eysuvis | cyclosporine | Miebo | Tyrvaya | Verkazia)
PDF, 166 KB
Opioids (All Preferred and Non-Preferred) (Long-Acting and Short-Acting Opioids)
PDF, 231 KB
PDF, 231 KB
Opzelura
PDF, 186 KB
PDF, 186 KB
Oral Buprenorphine Products
PDF, 162 KB
PDF, 162 KB
Oravig
PDF, 126 KB
PDF, 126 KB
Orencia SQ (Pharmacy)
PDF, 167 KB
PDF, 167 KB
Orilissa
PDF, 162 KB
PDF, 162 KB
Orkambi
PDF, 191 KB
PDF, 191 KB
Otezla
PDF, 164 KB
PDF, 164 KB
Otrexup (Non-Preferred)
PDF, 137 KB
PDF, 137 KB
Oxervate
PDF, 205 KB
PDF, 205 KB
Oxlumo (Pharmacy Benefit)
PDF, 168 KB
PDF, 168 KB
Palforzia
PDF, 242 KB
PDF, 242 KB
Palynziq
PDF, 142 KB
PDF, 142 KB
Pancreatic Enzymes
(PREFERRED - Creon | Zenpep) (Non-Preferred - Pancreaze | Pertzye | Ultresa | Viokace)PDF, 177 KB
(PREFERRED - Creon | Zenpep) (Non-Preferred - Pancreaze | Pertzye | Ultresa | Viokace)PDF, 177 KB
Phosphodiesterase 5 Inhibitors (PDE-5)
(PREFERRED - Alyq | sildenafil tab | tadalafil tab) (Non-Preferred - Adcirca | Revatio | Liqrev | Tadliq)
PDF, 160 KB
(PREFERRED - Alyq | sildenafil tab | tadalafil tab) (Non-Preferred - Adcirca | Revatio | Liqrev | Tadliq)
PDF, 160 KB
Platelet Inhibitors
(PREFERRED-Brilinta | dipyridamole | clopidogrel | ticlopidine HCL | prasugrel)
PDF, 158 KB
(PREFERRED-Brilinta | dipyridamole | clopidogrel | ticlopidine HCL | prasugrel)
PDF, 158 KB
Potassium Binders
(Lokelma | Veltassa)
PDF, 168 KB
(Lokelma | Veltassa)
PDF, 168 KB
Prevymis tablets (Pharmacy)
PDF, 196 KB
PDF, 196 KB
Promacta
PDF, 226 KB
PDF, 226 KB
Proton Pump Inhibitors (PPI) Drugs
(PREFERRED PPIs - omeprazole Rx | pantoprazole tablets | pantoprazole suspension | Protonix suspension- no PA required for short-term use, less than 90 days)
PDF, 189 KB
(PREFERRED PPIs - omeprazole Rx | pantoprazole tablets | pantoprazole suspension | Protonix suspension- no PA required for short-term use, less than 90 days)
PDF, 189 KB
Pulmozyme inhalation solution
PDF, 206 KB
PDF, 206 KB
Purified Cortrophin Gel | HP Acthar Gel (Infantile Spasms)
PDF, 190 KB
PDF, 190 KB
Purified Cortrophin Gel | HP Acthar Gel (Myositis)
PDF, 163 KB
PDF, 163 KB
Purified Cortrophin Gel | HP Acthar Gel (Nephrotic Syndrome)
PDF, 211 KB
PDF, 211 KB
Purified Cortrophin Gel | HP Acthar Gel (Ocular Diseases)
PDF, 226 KB
PDF, 226 KB
Purified Cortrophin Gel | HP Acthar Gel (Other Indications)
PDF, 170 KB
PDF, 170 KB
Purified Cortrophin Gel | HP Acthar Gel (Sarcoidosis)
PDF, 146 KB
PDF, 146 KB
Purified Cortrophin Gel | HP Acthar Gel (Systemic Lupus Erythematosus)
PDF, 200 KB
PDF, 200 KB
pyrimethamine (Daraprim)
PDF, 161 KB
PDF, 161 KB
Pyrukynd
PDF, 191 KB
PDF, 191 KB
Quinolones (Oral)
(PREFERRED-ciprofloxacin susp, tab | levofloxacin tab - does not require PA) (Non-Preferred-Baxdela IV | Cipro IR, XR, susp | ciprofloxacin ER | Noroxin | ofloxacin | Levaquin tab, susp | levofloxacin susp | moxifloxacin)
PDF, 188 KB
(PREFERRED-ciprofloxacin susp, tab | levofloxacin tab - does not require PA) (Non-Preferred-Baxdela IV | Cipro IR, XR, susp | ciprofloxacin ER | Noroxin | ofloxacin | Levaquin tab, susp | levofloxacin susp | moxifloxacin)
PDF, 188 KB
Radicava ORS
PDF, 197 KB
PDF, 197 KB
Rasuvo (Non-Preferred)
PDF, 138 KB
PDF, 138 KB
Ravicti
PDF, 175 KB
PDF, 175 KB
Rayaldee
PDF, 160 KB
PDF, 160 KB
Reditrex (Non-Preferred)
PDF, 157 KB
PDF, 157 KB
Relyvrio
PDF, 185 KB
PDF, 185 KB
Rezurock
PDF, 158 KB
PDF, 158 KB
Rinvoq
PDF, 175 KB
PDF, 175 KB
Savaysa (Non-Preferred)
PDF, 168 KB
PDF, 168 KB
Sernivo Spray (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Sickle Cell Drugs
(PREFERRED - Droxia | Endari | Oxbryta) (Non-Preferred - Adakveo IV | Siklos)
PDF, 212 KB
(PREFERRED - Droxia | Endari | Oxbryta) (Non-Preferred - Adakveo IV | Siklos)
PDF, 212 KB
Siliq SQ Injection
PDF, 167 KB
PDF, 167 KB
Simponi SQ (Pharmacy benefit)
PDF, 169 KB
PDF, 169 KB
Sivextro tablets (Pharmacy benefit)
PDF, 183 KB
PDF, 183 KB
Skyclarys
PDF, 196 KB
PDF, 196 KB
Skyrizi
PDF, 211 KB
PDF, 211 KB
Sodium Oxybate Products
(Lumryz | Sodium Oxybate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 218 KB
(Lumryz | Sodium Oxybate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 218 KB
Sodium Phenylbutyrate Products
(sodium phenylbutyrate | Pheburane | Olpruva)
PDF, 144 KB
(sodium phenylbutyrate | Pheburane | Olpruva)
PDF, 144 KB
Sohonos
PDF, 173 KB
PDF, 173 KB
Soma (Non-Preferred)
PDF, 160 KB
PDF, 160 KB
Somatostatin Analog Drugs (Pharmacy)
(Bynfezia SQ injection | lancreotide acetate ER SQ injection | Mycapssa | ocreotide injection | Sandostatin LAR Depot | Signifor SQ injection | Somavert injection)
PDF, 192 KB
(Bynfezia SQ injection | lancreotide acetate ER SQ injection | Mycapssa | ocreotide injection | Sandostatin LAR Depot | Signifor SQ injection | Somavert injection)
PDF, 192 KB
Sotyktu
PDF, 186 KB
PDF, 186 KB
Spravato (Pharmacy)
PDF, 184 KB
PDF, 184 KB
Stelara SQ (Pharmacy benefit)
PDF, 196 KB
PDF, 196 KB
Strensiq
PDF, 207 KB
PDF, 207 KB
Sucraid
PDF, 182 KB
PDF, 182 KB
Symdeko
PDF, 209 KB
PDF, 209 KB
SymLin | SymLinPen (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Synagis (Season October 1 through March 31) (Pharmacy benefit for Medicaid Members)
PDF, 894 KB
PDF, 894 KB
Taltz SQ (Pharmacy benefit) (Non-Preferred)
PDF, 183 KB
PDF, 183 KB
Tavalisse
PDF, 215 KB
PDF, 215 KB
Tezspire (Pharmacy)
PDF, 231 KB
PDF, 231 KB
tolvaptan (Samsca)
PDF, 154 KB
PDF, 154 KB
Topical Acne Drugs - Dermatologic (Non-Preferred and/or 18 Years of Age or Older)
PDF, 194 KB
PDF, 194 KB
Topical Immunomodulators
(Zyclara 2.5% Pump | Zyclara 3.75% Packets/Pump | imiquimod 3.75% packets/pump | Picato | Klisyri )
PDF, 160 KB
(Zyclara 2.5% Pump | Zyclara 3.75% Packets/Pump | imiquimod 3.75% packets/pump | Picato | Klisyri )
PDF, 160 KB
Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
(PREFERRED-diclofenac sodium 1% gel OTC/RX (generic Voltaren gel))
PDF, 172 KB
(PREFERRED-diclofenac sodium 1% gel OTC/RX (generic Voltaren gel))
PDF, 172 KB
Tremfya Injection
PDF, 179 KB
PDF, 179 KB
Trexall (Non-Preferred)
PDF, 132 KB
PDF, 132 KB
Trikafta
PDF, 190 KB
PDF, 190 KB
Ulesfia Lotion
PDF, 162 KB
PDF, 162 KB
Upneeq opthalmic solution 01%
PDF, 201 KB
PDF, 201 KB
Vemlidy
PDF, 170 KB
PDF, 170 KB
Verquvo
PDF, 207 KB
PDF, 207 KB
Vijoice
PDF, 183 KB
PDF, 183 KB
Vivjoa
PDF, 205 KB
PDF, 205 KB
Vowst
PDF, 169 KB
PDF, 169 KB
Voxzogo
PDF, 196 KB
PDF, 196 KB
Vuity opthalmic solution (Non-Preferred)
PDF, 134 KB
PDF, 134 KB
Vyndaqel | Vyndamax
PDF, 200 KB
PDF, 200 KB
Vyvanse Binge Eating Disorder (BED)
PDF, 161 KB
PDF, 161 KB
Weight Loss Management
(PREFERRED - Adipex-P/Suprenza | Bontril/Bontril PDM | Didrex/Regimex | Radtue | Saxenda | Wegovy | Xenical) (Non-Preferred - Imcivree | Zepbound)
PDF, 231 KB
(PREFERRED - Adipex-P/Suprenza | Bontril/Bontril PDM | Didrex/Regimex | Radtue | Saxenda | Wegovy | Xenical) (Non-Preferred - Imcivree | Zepbound)
PDF, 231 KB
Xadago
PDF, 133 KB
PDF, 133 KB
Xatmep (Non-Preferred)
PDF, 184 KB
PDF, 184 KB
Xdemvy
PDF, 156 KB
PDF, 156 KB
Xeljanz | Xeljanz XR (Pharmacy benefit) (Non-Preferred)
PDF, 212 KB
PDF, 212 KB
Xenleta
PDF, 141 KB
PDF, 141 KB
Xolair (Pharmacy)
PDF, 475 KB
PDF, 475 KB
Yulperi
PDF, 153 KB
PDF, 153 KB
Zeposia - Ulcerative Colitis Indication
PDF, 138 KB
PDF, 138 KB
Zokinvy
PDF, 226 KB
PDF, 226 KB
Zontivity (Non-Preferred)
PDF, 172 KB
PDF, 172 KB
Ztalmy
PDF, 136 KB
PDF, 136 KB
Zurzuvae
PDF, 163 KB
PDF, 163 KB
Zyvox
PDF, 162 KB
PDF, 162 KB
Medical Benefit Drugs
Abecma (Medical)
PDF, 246 KB
PDF, 246 KB
Abrysvo (Medical)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 158 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 158 KB
Actemra CRS (Medical)
Cytokine Release Syndrome (CRS)PDF, 189 KB
Cytokine Release Syndrome (CRS)PDF, 189 KB
Actemra IV (Medical)
(Infusion)PDF, 179 KB
(Infusion)PDF, 179 KB
Actimmune (Medical)
PDF, 152 KB
PDF, 152 KB
Adakveo (Medical)
PDF, 213 KB
PDF, 213 KB
Adasuve (Medical)
PDF, 177 KB
PDF, 177 KB
Adstiladrin (Medical)
PDF, 220 KB
PDF, 220 KB
Aduhelm IV (Medical)
PDF, 357 KB
PDF, 357 KB
Aldurazyme IV (Medical)
PDF, 248 KB
PDF, 248 KB
Aliqopa IV (Medical)
(Infusion)PDF, 165 KB
(Infusion)PDF, 165 KB
Alpha Protein Inhibitors (Medical)
(Aralast NP | Glassia | Prolastin-C | Zemaira)PDF, 208 KB
(Aralast NP | Glassia | Prolastin-C | Zemaira)PDF, 208 KB
Amphotericin B Liposome (Medical)
PDF, 208 KB
PDF, 208 KB
Amvuttra SQ | Onpattro IV (Medical)
PDF, 262 KB
PDF, 262 KB
Aphexda (Medical)
PDF, 186 KB
PDF, 186 KB
Azedra IV (Medical)
PDF, 278 KB
PDF, 278 KB
Beleodaq (Medical)
PDF, 190 KB
PDF, 190 KB
Benlysta IV (Medical)
(Infusion)PDF, 289 KB
(Infusion)PDF, 289 KB
Besponsa IV (Medical)
PDF, 213 KB
PDF, 213 KB
Beyfortus (Medical)
PDF, 208 KB
PDF, 208 KB
Botox | Xeomin (Medical)
Botulinum Toxin Injections, Type A (Botox | Xeomin)PDF, 205 KB
Botulinum Toxin Injections, Type A (Botox | Xeomin)PDF, 205 KB
Botox Injections (Type A) - Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS) (Medical)
Botulinum Toxin Injections, Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS))
PDF, 146 KB
Botulinum Toxin Injections, Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS))
PDF, 146 KB
Botox Injection-Type A (Chronic Migraine Headache Prophylaxis) (Medical)
Botulinum Toxin Injections, Type A (Chronic Migraine Headache Prophylaxis)PDF, 213 KB
Botulinum Toxin Injections, Type A (Chronic Migraine Headache Prophylaxis)PDF, 213 KB
Botox Injection-Type A (Hyperhidrosis) (Medical)
Botulinum Toxin Injections, Type A (Hyperhidrosis)PDF, 195 KB
Botulinum Toxin Injections, Type A (Hyperhidrosis)PDF, 195 KB
Breyanzi IV (Medical)
PDF, 243 KB
PDF, 243 KB
Brineura IV (Medical)
PDF, 166 KB
PDF, 166 KB
Briumvi (Medical)
PDF, 198 KB
PDF, 198 KB
Brixadi (Medical)
PDF, 164 KB
PDF, 164 KB
Carvykti (Medical)
PDF, 263 KB
PDF, 263 KB
Casgevy (Medical)
PDF, 260 KB
PDF, 260 KB
Cimzia (Medical)
PDF, 184 KB
PDF, 184 KB
Cinqair IV (Medical)
(Infusion)PDF, 173 KB
(Infusion)PDF, 173 KB
Cosentyx IV (Medical)
PDF, 198 KB
PDF, 198 KB
Cresemba (Medical)
PDF, 192 KB
PDF, 192 KB
Crysvita (Medical)
PDF, 152 KB
PDF, 152 KB
Dalvance (Medical)
PDF, 192 KB
PDF, 192 KB
Daxxify (Medical)
PDF, 171 KB
PDF, 171 KB
Dextenza (Medical)
PDF, 192 KB
PDF, 192 KB
Duchenne Muscular Dystrophy (DMD) Medications (Medical)
(Amondys 45 | Exondys 51 | Viltepso | Vyondys 53)
PDF, 181 KB
(Amondys 45 | Exondys 51 | Viltepso | Vyondys 53)
PDF, 181 KB
Duopa (Medical)
PDF, 170 KB
PDF, 170 KB
Durysta (Medical)
PDF, 169 KB
PDF, 169 KB
Dysport (Medical)
Botulinum Toxin Injections, Type A (Dysport)PDF, 218 KB
Botulinum Toxin Injections, Type A (Dysport)PDF, 218 KB
Elaprase IV (Medical)
(Infusion Only)PDF, 230 KB
(Infusion Only)PDF, 230 KB
Elelyso IV (Medical)
PDF, 162 KB
PDF, 162 KB
Elevidys (Medical)
PDF, 170 KB
PDF, 170 KB
Elfabrio IV (Medical)
PDF, 224 KB
PDF, 224 KB
Elzonris (Medical)
PDF, 188 KB
PDF, 188 KB
Empaveli (Medical)
Paroxysmal Nocturnal Hemoglobinuria (PNH)PDF, 207 KB
Paroxysmal Nocturnal Hemoglobinuria (PNH)PDF, 207 KB
Enjaymo (Medical)
PDF, 248 KB
PDF, 248 KB
Entyvio IV (Medical)
PDF, 171 KB
PDF, 171 KB
Evenity (Medical)
PDF, 201 KB
PDF, 201 KB
Evkeeza (Medical)
PDF, 230 KB
PDF, 230 KB
Eylea - Retinopathy of Prematurity (ROP) (Medical)
Retinopathy of Prematurity (ROP)PDF, 167 KB
Retinopathy of Prematurity (ROP)PDF, 167 KB
Fabrazyme IV (Medical)
(Infusion Only)PDF, 209 KB
(Infusion Only)PDF, 209 KB
Fasenra SQ (Medical)
PDF, 206 KB
PDF, 206 KB
Fetroja IV (Medical)
PDF, 178 KB
PDF, 178 KB
Folotyn (Medical)
PDF, 189 KB
PDF, 189 KB
Fuzeon (Medical)
PDF, 204 KB
PDF, 204 KB
Gamifant IV (Medical)
(Infusion Only)PDF, 250 KB
(Infusion Only)PDF, 250 KB
Gaucher Disease Drugs (Enzyme Replacement Therapy) (Medical)
(Cerezyme | Elelyso | Vpriv)PDF, 207 KB
(Cerezyme | Elelyso | Vpriv)PDF, 207 KB
Givlaari (Medical)
PDF, 226 KB
PDF, 226 KB
Gonadotropin-releasing Hormone Agonists (GnRH) Gender Dysphoria (Medical)
(PREFERRED: Eligard (3-month, 4-month, 6-month) | Lupron Depot (3-month, 4-month, 6-month)) | Lupron Depot-Ped (3-month) | Trelstar (3-month) | Supprelin LA | Vantas) (Non-Preferred: Camcevi | Eligard (1-month) | Fensolvi | leuprolide acetate | Lupron Depot (1-month) | Lupron Depot-Ped (1-month) | Trelstar (1-month) | Zoladex)PDF, 221 KB
(PREFERRED: Eligard (3-month, 4-month, 6-month) | Lupron Depot (3-month, 4-month, 6-month)) | Lupron Depot-Ped (3-month) | Trelstar (3-month) | Supprelin LA | Vantas) (Non-Preferred: Camcevi | Eligard (1-month) | Fensolvi | leuprolide acetate | Lupron Depot (1-month) | Lupron Depot-Ped (1-month) | Trelstar (1-month) | Zoladex)PDF, 221 KB
Granulocyte Colony-Stimulating Factors (G-CSFs)(G-CSFs)(GM-CSF) (Medical)
Short-Acting Granulocyte Colony-Stimulating Factors (G-CSFs); Granulocyte-macrophage Colony-Stimulating Factor (GM-CSF); Long-Acting Granulocyte Colony-Stimulating Factors (G-CSFs)
PDF, 194 KB
Short-Acting Granulocyte Colony-Stimulating Factors (G-CSFs); Granulocyte-macrophage Colony-Stimulating Factor (GM-CSF); Long-Acting Granulocyte Colony-Stimulating Factors (G-CSFs)
PDF, 194 KB
Hemgenix (Medical)
PDF, 263 KB
PDF, 263 KB
Hyaluronate Acids (Medical)
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | Triluron | TriVisc | Visco-3)PDF, 231 KB
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | Triluron | TriVisc | Visco-3)PDF, 231 KB
Ilaris (sJIA | AOSD) (Medical) (Non-Preferred)
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA) OR Adult Onset Still's Disease (AOSD)PDF, 277 KB
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA) OR Adult Onset Still's Disease (AOSD)PDF, 277 KB
Ilaris (TRAPS | HIDS/MKD | FMF diseases | CAPS) (Medical)
This form is applicable for the following diagnoses: Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF) and Cryopyrin-Associated Periodic Syndromes (CAPS)PDF, 233 KB
This form is applicable for the following diagnoses: Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF) and Cryopyrin-Associated Periodic Syndromes (CAPS)PDF, 233 KB
Ilumya (Medical)
PDF, 178 KB
PDF, 178 KB
Imlygic (Medical)
PDF, 203 KB
PDF, 203 KB
Immune Globulin Intravenous (IVIG) (immunodeficiency SQ ) (Medical)
(Gammagard | Gammunex-C | Hizentra | Hyqvia | Cuvitru)PDF, 228 KB
(Gammagard | Gammunex-C | Hizentra | Hyqvia | Cuvitru)PDF, 228 KB
Immune Globulin Intravenous (IVIG) (immunodeficiency) (CIDP) (Medical)
Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)PDF, 203 KB
Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)PDF, 203 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Disorders) (Medical)
(Autoimmune blistering disorders | Immune Thrombocytopenic Purpura | Guillain-Barre Syndrome | HIV Infection for children)PDF, 294 KB
(Autoimmune blistering disorders | Immune Thrombocytopenic Purpura | Guillain-Barre Syndrome | HIV Infection for children)PDF, 294 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Sjögren’s Syndrome Neuropathies) (Medical)
Miscellaneous Sjögren’s Syndrome NeuropathiesPDF, 256 KB
Miscellaneous Sjögren’s Syndrome NeuropathiesPDF, 256 KB
Immune Globulin Intravenous (IVIG) (Multifocal Motor Neuropathy (MMN)) (Medical)
Multifocal Motor Neuropathy (MMN)PDF, 221 KB
Multifocal Motor Neuropathy (MMN)PDF, 221 KB
Immune Globulin Intravenous (IVIG) (Primary Immunodeficiency Disorder (PID)) (Medical)
(Asceniv | Bivigam | Carimune NF | Flebogamma DIF | Gammagard | Gammaked | Gammaplex | Gamunex-C | Octagam | Panzyga | Privigen)PDF, 231 KB
(Asceniv | Bivigam | Carimune NF | Flebogamma DIF | Gammagard | Gammaked | Gammaplex | Gamunex-C | Octagam | Panzyga | Privigen)PDF, 231 KB
Infliximab (generic Remicade®) (Preferred) (Medical)
(PREFERRED: Infliximab (generic Remicade®)) (Non-Preferred: Avsola | Inflectra | Remicade | Renflexis)
PDF, 188 KB
(PREFERRED: Infliximab (generic Remicade®)) (Non-Preferred: Avsola | Inflectra | Remicade | Renflexis)
PDF, 188 KB
Intravitreal Complement Inhibitors (Medical)
(Izervay | Syfovre)
PDF, 199 KB
(Izervay | Syfovre)
PDF, 199 KB
Istodax | romidepsin (Medical)
PDF, 185 KB
PDF, 185 KB
Jesduvroq (Medical)
PDF, 174 KB
PDF, 174 KB
Kanuma IV (Medical)
(Infusion)PDF, 196 KB
(Infusion)PDF, 196 KB
Kepivance (Medical)
PDF, 213 KB
PDF, 213 KB
Kimyrsa | Orbactiv (Medical)
PDF, 194 KB
PDF, 194 KB
Korsuva (Medical)
PDF, 197 KB
PDF, 197 KB
Krystexxa (Medical)
PDF, 242 KB
PDF, 242 KB
Kybella IV (Medical)
PDF, 211 KB
PDF, 211 KB
Kymriah (Medical)
PDF, 244 KB
PDF, 244 KB
Lamzede (Medical)
PDF, 184 KB
PDF, 184 KB
Lantidra (Medical)
PDF, 198 KB
PDF, 198 KB
Lemtrada (Medical)
PDF, 169 KB
PDF, 169 KB
Leqembi IV (Medical)
PDF, 670 KB
PDF, 670 KB
Leqvio (Medical)
PDF, 238 KB
PDF, 238 KB
Lumizyme (Medical)
PDF, 194 KB
PDF, 194 KB
Lumoxiti (Medical)
PDF, 209 KB
PDF, 209 KB
Lutathera IV (Medical)
PDF, 246 KB
PDF, 246 KB
Luxturna (Medical)
(Drug should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in performing intraocular surgery)PDF, 185 KB
(Drug should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in performing intraocular surgery)PDF, 185 KB
Lyfgenia (Medical)
PDF, 279 KB
PDF, 279 KB
Macular Degeneration Drugs (Medical)
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Eylea HD | Lucentis | Susvimo | Vabysmo)
PDF, 263 KB
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Eylea HD | Lucentis | Susvimo | Vabysmo)
PDF, 263 KB
Mepsevii IV (Medical)
PDF, 174 KB
PDF, 174 KB
Mometasone Sinus Implants (Medical)
(Propel | Sinuva)PDF, 168 KB
(Propel | Sinuva)PDF, 168 KB
Mozobil (Medical)
PDF, 215 KB
PDF, 215 KB
Mylotarg (Medical)
PDF, 201 KB
PDF, 201 KB
Myobloc (Medical)
Botulinum Toxin Injections, Type B (Myobloc)PDF, 172 KB
Botulinum Toxin Injections, Type B (Myobloc)PDF, 172 KB
Naglazyme IV (Medical)
(Infusion)PDF, 199 KB
(Infusion)PDF, 199 KB
Nexviazyme | Pombiliti (Medical)
PDF, 263 KB
PDF, 263 KB
Noninfectious Uveitis (NIU) Drugs (Medical)
(Retisert | Yutiq)PDF, 204 KB
(Retisert | Yutiq)PDF, 204 KB
Nplate (Medical)
PDF, 241 KB
PDF, 241 KB
Nucala - Chronic Rhinosinusitis with Nasal Polyps (CRSWNP) (Medical)
PDF, 193 KB
PDF, 193 KB
Nucala - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Medical)
PDF, 234 KB
PDF, 234 KB
Nucala - Hypereosinophilic Syndrome (HES) (Medical)
PDF, 186 KB
PDF, 186 KB
Nucala - Severe Eosinophilic Asthma (SEA) (Medical)
PDF, 205 KB
PDF, 205 KB
Nulibry IV (Medical)
PDF, 240 KB
PDF, 240 KB
Nulojix (Medical)
PDF, 210 KB
PDF, 210 KB
Nuzyra IV (Medical)
PDF, 184 KB
PDF, 184 KB
Ocrevus (Medical)
PDF, 169 KB
PDF, 169 KB
Omisirge (Medical)
PDF, 233 KB
PDF, 233 KB
Ophthalmic Corticosteroid Injections (Medical)
(Ozurdex | Iluvien | Xipere)PDF, 231 KB
(Ozurdex | Iluvien | Xipere)PDF, 231 KB
Orencia IV (Infusion) (Medical)
(Infusion Only)PDF, 218 KB
(Infusion Only)PDF, 218 KB
Orencia IV Graft Versus Host Disease (GVHD) (Medical)
(Infusion Only)PDF, 199 KB
(Infusion Only)PDF, 199 KB
Oxlumo (Medical)
PDF, 180 KB
PDF, 180 KB
Panhematin (Medical)
PDF, 186 KB
PDF, 186 KB
Parenteral Iron Products (Medical)
(Non-Preferred) Feraheme | Injectafer | MonoferricPDF, 150 KB
(Non-Preferred) Feraheme | Injectafer | MonoferricPDF, 150 KB
Pluvicto IV (Medical)
PDF, 230 KB
PDF, 230 KB
Prevymis IV (Infusion) (Medical)
PDF, 213 KB
PDF, 213 KB
Prialt (Medical)
PDF, 141 KB
PDF, 141 KB
Primaxin IV (Medical)
PDF, 189 KB
PDF, 189 KB
Provenge (Medical)
PDF, 184 KB
PDF, 184 KB
Pulmonary Arterial Hypertension IV Drugs (Medical)
Phosphodiesterase Type-5 Inhibitors (sildenafil IV (Revatio)); Prostacyclin Pathway Agents - Analogues and Receptor Agonist (epoprostenol IV (Flolan) | epoprostenol IV (Veletri) | treprostinil IV (Remodulin) | Uptravi IV)PDF, 261 KB
Phosphodiesterase Type-5 Inhibitors (sildenafil IV (Revatio)); Prostacyclin Pathway Agents - Analogues and Receptor Agonist (epoprostenol IV (Flolan) | epoprostenol IV (Veletri) | treprostinil IV (Remodulin) | Uptravi IV)PDF, 261 KB
Qalsody (Medical)
PDF, 210 KB
PDF, 210 KB
Qutenza (Medical)
PDF, 142 KB
PDF, 142 KB
Radicava IV (Medical)
PDF, 227 KB
PDF, 227 KB
Reblozyl (Medical)
PDF, 224 KB
PDF, 224 KB
Rebyota (Medical)
PDF, 202 KB
PDF, 202 KB
Recarbrio (Medical)
PDF, 190 KB
PDF, 190 KB
Rezzayo IV (Medical)
PDF, 190 KB
PDF, 190 KB
Riabni | Rituxan IV | Ruxience | Truxima (Medical)
For any Oncology indications including the use of Rituxan Hycela, the most efficient way to submit a prior authorization request is through the AIM ProviderPortal at www.providerportal.comPDF, 243 KB
For any Oncology indications including the use of Rituxan Hycela, the most efficient way to submit a prior authorization request is through the AIM ProviderPortal at www.providerportal.comPDF, 243 KB
Rituxan - Pemphigus Vulgaris (Medical) (Non-Preferred)
PDF, 213 KB
PDF, 213 KB
Rituxan Hycela (Medical)
Medication being Provided by a Physicial's Offfice ONLYPDF, 167 KB
Medication being Provided by a Physicial's Offfice ONLYPDF, 167 KB
Roctavian (Medical)
PDF, 221 KB
PDF, 221 KB
Ryplazim (Medical)
PDF, 233 KB
PDF, 233 KB
Rystiggo (Medical)
PDF, 183 KB
PDF, 183 KB
Saphnelo IV (Medical)
PDF, 251 KB
PDF, 251 KB
Scenesse Implant (Medical)
PDF, 210 KB
PDF, 210 KB
Simponi ARIA IV (Medical) (Non-Preferred)
PDF, 195 KB
PDF, 195 KB
Simulect IV (Medical)
PDF, 173 KB
PDF, 173 KB
Sinuva Sinus Implant (Medical)
PDF, 200 KB
PDF, 200 KB
Sivextro (Medical)
PDF, 187 KB
PDF, 187 KB
Skysona (Medical)
PDF, 232 KB
PDF, 232 KB
Soliris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
PDF, 226 KB
PDF, 226 KB
Soliris IV - Generalized Myasthenia Gravis (gMG) (Medical)
PDF, 183 KB
PDF, 183 KB
Soliris IV - Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)
PDF, 247 KB
PDF, 247 KB
Soliris IV - Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
PDF, 245 KB
PDF, 245 KB
Somatostatin Analog Drugs (Medical)
PREFERRED (lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection); NON-PREFERRED (Somatuline Depot)
PDF, 162 KB
PREFERRED (lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection); NON-PREFERRED (Somatuline Depot)
PDF, 162 KB
Spevigo (Medical)
PDF, 189 KB
PDF, 189 KB
Spinraza (Medical)
PDF, 196 KB
PDF, 196 KB
Spravato (Medical)
PDF, 186 KB
PDF, 186 KB
Sunleca (Medical)
PDF, 224 KB
PDF, 224 KB
Sustol (Medical)
PDF, 195 KB
PDF, 195 KB
Sylvant (Medical)
PDF, 187 KB
PDF, 187 KB
Tecartus IV (Medical)
PDF, 243 KB
PDF, 243 KB
Teflaro IV (Medical)
PDF, 182 KB
PDF, 182 KB
Tegsedi SQ (Medical)
PDF, 196 KB
PDF, 196 KB
Tepezza (Medical)
PDF, 245 KB
PDF, 245 KB
Testosterone Replacement Therapy Injectable (Medical)
(Aveed | TestoPel) Medication being provided by the physician's officePDF, 221 KB
(Aveed | TestoPel) Medication being provided by the physician's officePDF, 221 KB
Tezspire (Medical)
PDF, 253 KB
PDF, 253 KB
Trogarzo IV (Medical)
Medication being provided by the physician's officePDF, 179 KB
Medication being provided by the physician's officePDF, 179 KB
Tygacil (Medical)
PDF, 202 KB
PDF, 202 KB
Tysabri IV (Medical)
PDF, 167 KB
PDF, 167 KB
Tzield (Medical)
PDF, 249 KB
PDF, 249 KB
Ultomiris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
PDF, 276 KB
PDF, 276 KB
Ultomiris IV - Generalized Myasthenia Gravis (gMG) (Medical)
PDF, 236 KB
PDF, 236 KB
Ultomiris IV - Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
PDF, 242 KB
PDF, 242 KB
Uplinza IV - Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)
PDF, 167 KB
PDF, 167 KB
Vabomere (Medical)
PDF, 160 KB
PDF, 160 KB
Valstar (Medical)
PDF, 185 KB
PDF, 185 KB
Veopoz (Medical)
PDF, 218 KB
PDF, 218 KB
Vibativ (Medical)
PDF, 181 KB
PDF, 181 KB
Vimizim IV (Medical)
IV Infusion Performed at Sentara Infusion Centers ONLYPDF, 213 KB
IV Infusion Performed at Sentara Infusion Centers ONLYPDF, 213 KB
Visudyne (Medical)
PDF, 202 KB
PDF, 202 KB
Vyepti IV (Medical)
PDF, 199 KB
PDF, 199 KB
Vyjuvek (Medical)
PDF, 223 KB
PDF, 223 KB
Vyvgart IV | Vyvgart Hytrulo (Medical)
PDF, 219 KB
PDF, 219 KB
Vyxeos (Medical)
PDF, 188 KB
PDF, 188 KB
Xacduro (Medical)
PDF, 225 KB
PDF, 225 KB
Xenleta IV (Medical)
PDF, 167 KB
PDF, 167 KB
Xenpozyme (Medical)
PDF, 210 KB
PDF, 210 KB
Xerava IV (Medical)
PDF, 177 KB
PDF, 177 KB
Xiaflex (Medical)
PDF, 198 KB
PDF, 198 KB
Xofigo IV (Medical)
PDF, 229 KB
PDF, 229 KB
Xolair (Medical)
PDF, 459 KB
PDF, 459 KB
Ycanth (Medical)
PDF, 167 KB
PDF, 167 KB
Yescarta (Medical)
PDF, 237 KB
PDF, 237 KB
Yondelis (Medical)
PDF, 184 KB
PDF, 184 KB
Zemdri IV (Medical)
PDF, 177 KB
PDF, 177 KB
Zevalin IV (Medical)
PDF, 228 KB
PDF, 228 KB
Zinplava (Medical)
PDF, 248 KB
PDF, 248 KB
Zolgensma IV (Medical)
PDF, 197 KB
PDF, 197 KB
Zulresso Injection (Medical)
(Behavioral Health Medical)PDF, 221 KB
(Behavioral Health Medical)PDF, 221 KB
Zynteglo (Medical)
PDF, 238 KB
PDF, 238 KB