Prescription Drug Authorization Forms — Medicaid Plans
Medicaid Pharmacy Special Exception Forms and Information
Compound Drugs Prior Authorization Request Form
PDF, 26 KB
PDF, 26 KB
Maximum Daily Dosage Limit Exception Form
PDF, 24 KB
PDF, 24 KB
Pancreatic Enzyme Utilization Criteria for Cystic Fibrosis Request
PDF, 31 KB
PDF, 31 KB
Orally Administered Oncology Medications
PDF, 200 KB
PDF, 200 KB
Pharmacy Medical Drug Necessity Request
PDF, 34 KB
PDF, 34 KB
Medical Drug Authorization Changes
Drug Authorization Forms
Abecma (Medical)
PDF, 243 KB
PDF, 243 KB
Abrysvo
PDF, 117 KB
PDF, 117 KB
Actemra (diagnosis of Giant Cell Arteritis)
PDF, 214 KB
PDF, 214 KB
Actemra (diagnosis of Systemic Sclerosis-associated Interstitial Lung Disease)
PDF, 217 KB
PDF, 217 KB
Actemra IV (Medical)
PDF, 116 KB
PDF, 116 KB
Actemra IV for diagnosis of Cytokine Release Syndrome (CRS) (Medical)
PDF, 84 KB
PDF, 84 KB
Actemra SQ (Pharmacy) (Non-Preferred)
PDF, 202 KB
PDF, 202 KB
Actimmune (Medical)
PDF, 42 KB
PDF, 42 KB
ActimmuneSQ
PDF, 196 KB
PDF, 196 KB
Adakveo (Medical)
PDF, 204 KB
PDF, 204 KB
Adbry
PDF, 255 KB
PDF, 255 KB
Addyi
PDF, 157 KB
PDF, 157 KB
Adefovir dipivoxil (ADV, generic Hepsera)
PDF, 195 KB
PDF, 195 KB
Adsiladrin (Medical)
PDF, 222 KB
PDF, 222 KB
Aduhelm (Medical)
PDF, 284 KB
PDF, 284 KB
Afrezza
PDF, 31 KB
PDF, 31 KB
AirDuo RespiClick | AirDuo Digihaler | budesonide-formoterol | Dulera | fluticasone-salmeterol | fluticasone furoate-vilanterol | Wixela Inhub
PDF, 168 KB
PDF, 168 KB
Albuterol Inhalers (albuterol HFA (generic ProAir HFA) | albuterol HFA (generic Proventil HFA) | albuterol HFA (generic Ventolin HFA) | lavalbuterol HFA (generic Xopenex) | ProAir Digihaler/HFA/Respiclick | Proventil HFA)
PDF, 143 KB
PDF, 143 KB
Aldurazyme (Medical)
PDF, 123 KB
PDF, 123 KB
Alinia
PDF, 38 KB
PDF, 38 KB
Aliqopa IV (Medical)
PDF, 55 KB
PDF, 55 KB
Alpha Proteinase Inhibitors (Aralast NP | Glassia | Prolastin-C | Zemaira) (Medical)
PDF, 224 KB
PDF, 224 KB
Alvesco | ArmonAir Digihaler | fluticasone propionate HFA | Pulmicort
PDF, 143 KB
PDF, 143 KB
Amvuttra | Onpattro (Medical)
PDF, 264 KB
PDF, 264 KB
Anticonvulsants | Antiepileptic Drugs | Antiseizure Drugs
PDF, 229 KB
PDF, 229 KB
Antipsychotics-Children (0-17 yrs) - COMMERCIAL ONLY
PDF, 43 KB
PDF, 43 KB
Apokyn | Kynmobi
PDF, 170 KB
PDF, 170 KB
Aranesp | Epogen | Procrit | Retacrit
PDF, 38 KB
PDF, 38 KB
Arcalyst
PDF, 317 KB
PDF, 317 KB
Arcapta Neohaler
PDF, 151 KB
PDF, 151 KB
Arformoterol nebulizer solution (generic Brovana & ABA)
PDF, 129 KB
PDF, 129 KB
Arikayce
PDF, 32 KB
PDF, 32 KB
Atypical Antipsychotics (asenapine | Caplyta | Fanapt |lurasidone | paliperidone | Rexulti | Vraylar)
PDF, 180 KB
PDF, 180 KB
Auryxia | lanthanum chewable tablet | Velphoro
PDF, 23 KB
PDF, 23 KB
Austedo
PDF, 181 KB
PDF, 181 KB
Auvelity
PDF, 158 KB
PDF, 158 KB
Auvi-Q Auto-Injector
PDF, 204 KB
PDF, 204 KB
Aveed | TestoPel (Medical) (Testosterone Replacement Therapy will be purchased by physician's office)
PDF, 222 KB
PDF, 222 KB
Azedra (Medical)
PDF, 273 KB
PDF, 273 KB
Benlysta (Medical)
PDF, 207 KB
PDF, 207 KB
Benlysta (Pharmacy)
PDF, 291 KB
PDF, 291 KB
Berinert IV (Medical)
PDF, 43 KB
PDF, 43 KB
Besponsa IV (Medical)
PDF, 66 KB
PDF, 66 KB
Bevespi Aerosphere | Breztri | Duaklir Pressair | Utibron Neohaler
PDF, 54 KB
PDF, 54 KB
Beyfortus (Medical)
PDF, 231 KB
PDF, 231 KB
BOTOX | Xeomin Injections (Medical) (Cosmetic indications are Excluded)
PDF, 201 KB
PDF, 201 KB
Botox Injection (Type A) - Chronic Migraine Headache Prophylaxis (Medical)
PDF, 206 KB
PDF, 206 KB
BOTOX Injections - Chronic Migraine Headache Prophylaxis (Medical) (Cosmetic indications Excluded)
PDF, 233 KB
PDF, 233 KB
BOTOX Injections - Hyperhidrosis (Medical) (Cosmetic indications Excluded)
PDF, 212 KB
PDF, 212 KB
BOTOX Injections - Upper Limb Spasticity (ULS) | Lower Limb Spasticity (Medical) (Cosmetic indications Excluded)
PDF, 39 KB
PDF, 39 KB
Brexafemme
PDF, 185 KB
PDF, 185 KB
Breyanzi (Medical)
PDF, 246 KB
PDF, 246 KB
Brineura IV (Medical)
PDF, 39 KB
PDF, 39 KB
Brixadi│Sublocade
PDF, 184 KB
PDF, 184 KB
Bronchitol
PDF, 209 KB
PDF, 209 KB
Bylvay
PDF, 232 KB
PDF, 232 KB
Cabenuva (Medical)
PDF, 181 KB
PDF, 181 KB
Cabenuva (Pharmacy)
PDF, 155 KB
PDF, 155 KB
Cablivi
PDF, 73 KB
PDF, 73 KB
Camzyos
PDF, 144 KB
PDF, 144 KB
Candesartan | candesartan-HCTZ | Edarbi | Edarbyclor | Tekturna | Tekturna HCT
PDF, 214 KB
PDF, 214 KB
Carglumic acid (Carbaglu)
PDF, 199 KB
PDF, 199 KB
Carvykti (Medical)
PDF, 265 KB
PDF, 265 KB
Central Nervous System (CNS) Stimulants (Age 19 and Above) (Adhansia XR | Adzenys XR-ODT/ER | amphetamine/dextroamphetamine (Adderall) |amphetamine/dextroamphetamine ER (Adderall XR) | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR/ODT | dexmethylphenidate (Focalin) | dexmethylphenidate ER (Focalin XR) | dextroamphetamine (Zenzedi) | dextroamphetamine (ProCentra) | dextroamphetamine (Dextrostat) | dextroamphetamine ER (Dexedrine Spansule) | Dyanavel XR | Evekeo ODT | Jornay PM | methamphetamine (Desoxyn) | methylphenidate ER (Aptensio XR) | methylphenidate ER (Concerta) | methylphenidate TID Patch (Daytrana) | methylphenidate ER (Ritalin SR/Metadate ER) | methylphenidate (Ritalin/Methylin) | methylphenidate LA (Ritalin LA) | methylphenidate CD (Metadate CD) | Mydays | Quillichew ER | Quillivant XR | Vyvanse)
PDF, 182 KB
PDF, 182 KB
Central Nervous System (CNS) Stimulants (Non-Preferred) (Adhansia XR | Adzenys XR-ODT | Adzenys ER Susp | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR-ODT | Dyanavel XR | Evekeo ODT | Jornay PM | methylphenidate ER (Aptensio XR) | methylphenidate TD Patch (Daytrana) | Mydayis | Quillichew ER | Quillivant XR
PDF, 171 KB
PDF, 171 KB
Cequa | Lacrisert | Tyrvaya
PDF, 163 KB
PDF, 163 KB
Cerdelga
PDF, 95 KB
PDF, 95 KB
Cholbam
PDF, 186 KB
PDF, 186 KB
Cialis | tadalafil (BPH) ONLY
PDF, 147 KB
PDF, 147 KB
Cibinqo
PDF, 180 KB
PDF, 180 KB
Cimzia Lyophilized IV (Medical)
PDF, 65 KB
PDF, 65 KB
Cimzia SQ (Pharmacy benefit Prefilled syringe)
PDF, 201 KB
PDF, 201 KB
Cinacalcet (generic Sensipar)
PDF, 204 KB
PDF, 204 KB
Cinqair IV (Medical)
PDF, 170 KB
PDF, 170 KB
Compound Drugs
PDF, 75 KB
PDF, 75 KB
Continuous Glucose Monitors (CGM) & Subcutaneous Insulin Pumps (group specific benefit)
PDF, 181 KB
PDF, 181 KB
Corlanor
PDF, 186 KB
PDF, 186 KB
Cosentyx SQ (Pharmacy benefit)
PDF, 227 KB
PDF, 227 KB
Cresemba (Medical)
PDF, 90 KB
PDF, 90 KB
Cresemba (Pharmacy)
PDF, 62 KB
PDF, 62 KB
Crinone
PDF, 149 KB
PDF, 149 KB
Crysvita Injection (Medical)
PDF, 216 KB
PDF, 216 KB
Cuvposa
PDF, 188 KB
PDF, 188 KB
Cuvrior | Syprine | trientine
PDF, 208 KB
PDF, 208 KB
Cystaran | Cystadrops
PDF, 184 KB
PDF, 184 KB
D.H.E. 45 | Migranal
PDF, 33 KB
PDF, 33 KB
Daraprim
PDF, 227 KB
PDF, 227 KB
Daybue
PDF, 281 KB
PDF, 281 KB
Deferasirox (generic Exjade) | deferasirox (generic Jadenu)
PDF, 212 KB
PDF, 212 KB
Deferiprone tablets (generic Ferriprox) | Ferriprox solution | Ferriprox 2-day tablets
PDF, 184 KB
PDF, 184 KB
Demser | Dibenzyline
PDF, 30 KB
PDF, 30 KB
Denavir
PDF, 153 KB
PDF, 153 KB
Depen Titratable tablets | Penicillamine tablets (PREFERRED) | Cuprimine | Penicillamine capsules (NON-PREFERRED)
PDF, 170 KB
PDF, 170 KB
Dextenza (Medical)
PDF, 194 KB
PDF, 194 KB
Diacomit
PDF, 155 KB
PDF, 155 KB
Diclegis
PDF, 153 KB
PDF, 153 KB
Dificid
PDF, 220 KB
PDF, 220 KB
Dojolvi
PDF, 97 KB
PDF, 97 KB
Doptelet
PDF, 208 KB
PDF, 208 KB
Dry Eye Medications (Cequa | Lacrisert | Miebo | Tyrvaya )
PDF, 171 KB
PDF, 171 KB
Duavee
PDF, 160 KB
PDF, 160 KB
Duchenne Muscular Dystrophy Medications (Amondys 45 | Exondys 51 | Viltepso | Vyondys 53) (Medical)
PDF, 188 KB
PDF, 188 KB
Duexis | Vimovo
PDF, 195 KB
PDF, 195 KB
Dupixent
PDF, 274 KB
PDF, 274 KB
Durysta (Medical)
PDF, 176 KB
PDF, 176 KB
Dysport (Botox Injections) (Medical) (Cosmetic indications Excluded)
PDF, 220 KB
PDF, 220 KB
Edecrin
PDF, 27 KB
PDF, 27 KB
Egaten
PDF, 27 KB
PDF, 27 KB
Egrifta
PDF, 27 KB
PDF, 27 KB
Elaprase IV (Medical)
PDF, 117 KB
PDF, 117 KB
Elevidys (Medical)
PDF, 172 KB
PDF, 172 KB
Elfabrio (Medical)
PDF, 220 KB
PDF, 220 KB
Elidel
PDF, 134 KB
PDF, 134 KB
Emflaza
PDF, 201 KB
PDF, 201 KB
Empaveli (Medical)
PDF, 208 KB
PDF, 208 KB
Emsam
PDF, 31 KB
PDF, 31 KB
Emverm
PDF, 195 KB
PDF, 195 KB
Enbrel
PDF, 194 KB
PDF, 194 KB
Endari
PDF, 33 KB
PDF, 33 KB
Enjaymo (Medical)
PDF, 249 KB
PDF, 249 KB
Enspryng
PDF, 166 KB
PDF, 166 KB
Entyvio IV (Medical)
PDF, 64 KB
PDF, 64 KB
Epidiolex
PDF, 203 KB
PDF, 203 KB
Esbriet
PDF, 163 KB
PDF, 163 KB
Eucrisa
PDF, 196 KB
PDF, 196 KB
Evenity (Medical)
PDF, 217 KB
PDF, 217 KB
Evkeeza (Medical)
PDF, 226 KB
PDF, 226 KB
Evrysdi
PDF, 185 KB
PDF, 185 KB
Evzio
PDF, 27 KB
PDF, 27 KB
Eylea - Retinopathy of Prematurity (ROP)
PDF, 185 KB
PDF, 185 KB
Ezetimibe/simvastatin (Vytorin)
PDF, 159 KB
PDF, 159 KB
Fabrazyme IV (Medical)
PDF, 214 KB
PDF, 214 KB
Fasenra SQ (Medical)
PDF, 204 KB
PDF, 204 KB
Fasenra SQ (Pharmacy)
PDF, 202 KB
PDF, 202 KB
Fetzima | Trintellix | Viibryd
PDF, 33 KB
PDF, 33 KB
Filspari
PDF, 185 KB
PDF, 185 KB
Fintepla
PDF, 194 KB
PDF, 194 KB
Firdapse
PDF, 175 KB
PDF, 175 KB
Flector Patch
PDF, 30 KB
PDF, 30 KB
Flucytosine
PDF, 155 KB
PDF, 155 KB
Forteo | Tymlos | teriparatide
PDF, 179 KB
PDF, 179 KB
Furoscix
PDF, 155 KB
PDF, 155 KB
Galafold
PDF, 170 KB
PDF, 170 KB
Gamifant (Medical)
PDF, 123 KB
PDF, 123 KB
Gastrointestinal Motility Drugs (PREFERRED Drugs require PA - Linzess | Movantik | Symproic) (Non-Preferred - Amitiza | Ibsrela | Motegrity | Relistor | Trulance | Zelnorm)
PDF, 182 KB
PDF, 182 KB
Gattex
PDF, 124 KB
PDF, 124 KB
Gaucher Disease Drugs (Enzyme Replacement Therapy) (Cerezyme | Elelyso | Vpriv) (Medical)
PDF, 208 KB
PDF, 208 KB
Gaucher Disease Drugs (Substrate Reduction Therapy) (Cerdelga | Miglustat) (Pharmacy)
PDF, 223 KB
PDF, 223 KB
Givlaari (Medical)
PDF, 113 KB
PDF, 113 KB
Glaucoma Drugs (Betimol | Betoptic-S | Rhopressa | Rocklatan | Simbrinza | travoprost 0.004% | Vyzulta | Zioptan)
PDF, 164 KB
PDF, 164 KB
Glucagon Analogs (GlucaGen HypoKit | Zegalogue)
PDF, 203 KB
PDF, 203 KB
Glucagon-like peptide (GLP-1) receptor agonists (Bydureon Bcise | Byetta | Mounjaro | Ozempic | Rybelsus | Trulicity | Victoza)
PDF, 169 KB
PDF, 169 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Medical)
PDF, 262 KB
PDF, 262 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Pharmacy)
PDF, 234 KB
PDF, 234 KB
Graft-Versus-Host Disease (GVHD) Drugs (Jakafi | Imbruvica)
PDF, 217 KB
PDF, 217 KB
Granulocyte Colony-Stimulating Factors (G-CSFs) (Fulphila | Granix | Leukine | Neupogen | Neulasta | Nivestym | Nyvepria | Releuko | Udenyca | Zarxio | Ziextenzo)
PDF, 193 KB
PDF, 193 KB
Grastex | Oralair
PDF, 167 KB
PDF, 167 KB
Hemangeol
PDF, 160 KB
PDF, 160 KB
Hemgenix (Medical)
PDF, 265 KB
PDF, 265 KB
Hemophilia Factors (IV) (Medical)
PDF, 167 KB
PDF, 167 KB
Hepatitis-C Antiviral (HCV) Drugs (PREFERRED: sofosbuvir/elpatasvir | ledipasvir/sofobuvir | Mavyret) (NON-PREFERRED: Epclusa | Harvoni | Sovaldi | Viekira Pak | Vosevi | Zepatier)
PDF, 337 KB
PDF, 337 KB
Hyaluronate Acids (Medical) (PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 237 KB
PDF, 237 KB
Icatibant (generic Firazyr) (Medical)
PDF, 198 KB
PDF, 198 KB
Icatibant | Sajazir (generic Firazyr) (Pharmacy)
PDF, 221 KB
PDF, 221 KB
Ilaris (sJIA | AOSD) (Medical) (Non-Preferred)
PDF, 277 KB
PDF, 277 KB
Ilaris (TRAPS | HIDS/MKD | FMF diseases | CAPS) (Medical)
PDF, 256 KB
PDF, 256 KB
Ilumya (Pharmacy)
PDF, 175 KB
PDF, 175 KB
Ilumya SQ (Medical) (Ilumya should ONLY be administered by a healthcare provider)
PDF, 173 KB
PDF, 173 KB
Imcivree
PDF, 206 KB
PDF, 206 KB
Imlygic (Medical)
PDF, 197 KB
PDF, 197 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Sjögren’s Syndrome Neuropathies) (Medical)
PDF, 265 KB
PDF, 265 KB
Inbrija | Nourianz | Ongentys | tolcapone
PDF, 179 KB
PDF, 179 KB
Increlex
PDF, 176 KB
PDF, 176 KB
Infliximab IV (PREFERRED: Renflexis) (Non-Preferred: Avsola | Inflectra | infliximab | Remicade) (Medical)
PDF, 231 KB
PDF, 231 KB
Ingrezza
PDF, 169 KB
PDF, 169 KB
Injectable Migraine Treatment (PREFERRED: Aimovig l Emgality) (NON-PREFERRED: Ajovy)
PDF, 171 KB
PDF, 171 KB
Inpefa
PDF, 145 KB
PDF, 145 KB
Insomnia Drugs (Belsomra | Dayvigo | quazepam | Quviviq | ramelteon)
PDF, 144 KB
PDF, 144 KB
INSULINS (Admelog | Apidra vial or SoloSTAR | Basaglar | Fiasp | insulin aspart | insuline lispro | Levemir | Lyumjev/Kwikpen | NovoLIN 70/30 | NovoLIN N | NovoLIN R | NovoLOG vial or FlexPen | NovoLOG Mix 70/30 vial or FlexPen | Semglee | Tresiba)
PDF, 36 KB
PDF, 36 KB
Isturisa
PDF, 194 KB
PDF, 194 KB
Ivermectin (generic Stomectol)
PDF, 133 KB
PDF, 133 KB
IVIG - Multifocal Motor Neuropathy (MMN) (Medical)
PDF, 94 KB
PDF, 94 KB
IVIG IV PID (Primary Immune Deficiency) (Medical)
PDF, 232 KB
PDF, 232 KB
IVIG Misc Disorders (Medical) (see form for list of diagnoses)
PDF, 129 KB
PDF, 129 KB
IVIG_SQ PID (Gammagard | Gamunex-C | Hizentra | Hyqvia | Cuvitru) (Medical)
PDF, 241 KB
PDF, 241 KB
IVIG-CIDP (Chronic Inflammatory Demyelinating Polyneuropathy) (Medical)
PDF, 116 KB
PDF, 116 KB
Joenja
PDF, 181 KB
PDF, 181 KB
Juxtapid
PDF, 48 KB
PDF, 48 KB
Jynarque
PDF, 102 KB
PDF, 102 KB
Kalbitor (Medical)
PDF, 43 KB
PDF, 43 KB
Kalydeco
PDF, 178 KB
PDF, 178 KB
Kanuma (Medical)
PDF, 214 KB
PDF, 214 KB
Kazano | KombiglyzeXR | Nesina | Onglyza | Oseni
PDF, 34 KB
PDF, 34 KB
Kerendia
PDF, 170 KB
PDF, 170 KB
Keveyis
PDF, 161 KB
PDF, 161 KB
Kevzara
PDF, 172 KB
PDF, 172 KB
Keytruda IV (Medical)
PDF, 79 KB
PDF, 79 KB
Kineret
PDF, 247 KB
PDF, 247 KB
Korlym
PDF, 170 KB
PDF, 170 KB
Korsuva (Medical)
PDF, 215 KB
PDF, 215 KB
Koselugo
PDF, 70 KB
PDF, 70 KB
Krystexxa IV (Medical)
PDF, 211 KB
PDF, 211 KB
Kuvan
PDF, 179 KB
PDF, 179 KB
Kymriah (Medical)
PDF, 268 KB
PDF, 268 KB
Lampit | benznidazole
PDF, 174 KB
PDF, 174 KB
Lamzede (Medical)
PDF, 184 KB
PDF, 184 KB
Lemtrada IV (Medical)
PDF, 172 KB
PDF, 172 KB
Leqembi (Medical)
PDF, 671 KB
PDF, 671 KB
Leqvio (Medical)
PDF, 237 KB
PDF, 237 KB
Litfulo
PDF, 148 KB
PDF, 148 KB
Livalo | Zypitamag
PDF, 155 KB
PDF, 155 KB
Livmarli
PDF, 174 KB
PDF, 174 KB
Livtencity
PDF, 254 KB
PDF, 254 KB
Lonhala Magnair | Tudorza Pressair | Yupelri
PDF, 179 KB
PDF, 179 KB
Lotronex | Viberzi
PDF, 229 KB
PDF, 229 KB
Lumizyme (Medical)
PDF, 191 KB
PDF, 191 KB
Lupkynis
PDF, 196 KB
PDF, 196 KB
Lutathera (Medical)
PDF, 264 KB
PDF, 264 KB
Luxturna (Medical) (Medication should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in intraocular surgery.)
PDF, 49 KB
PDF, 49 KB
Lyrica CR
PDF, 22 KB
PDF, 22 KB
Macular Degeneration Drugs IV (PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Eylea | Lucentis | Susvimo | Vabysmo) (Medical)
PDF, 228 KB
PDF, 228 KB
Makena (Medical)
PDF, 34 KB
PDF, 34 KB
Marplan
PDF, 141 KB
PDF, 141 KB
Mepsevii IV (Medical)
PDF, 62 KB
PDF, 62 KB
Mesalamine DR 800 mg | Dipentum | budesonide ER 9mg | Uceris (Irritable Bowel Disease) (Non-Preferred Commercial)
PDF, 33 KB
PDF, 33 KB
Mometasone Sinus Implants (Propel | Sinuva)
PDF, 170 KB
PDF, 170 KB
Mozobil (Medical)
PDF, 200 KB
PDF, 200 KB
Mulpleta
PDF, 46 KB
PDF, 46 KB
Multiple Sclerosis Drugs (Bafiertam | Extavia | Gilenya 0.5mg | Kesimpta | Mavenclad | Mayzent | Ponvory | Vumerity | Zeposia)
PDF, 193 KB
PDF, 193 KB
Myalept
PDF, 178 KB
PDF, 178 KB
Myfembree | Oriahnn
PDF, 196 KB
PDF, 196 KB
Myobloc (Botox Injection, Type B) (Medical) (Cosmetic indications Excluded)
PDF, 169 KB
PDF, 169 KB
Mytesi (formerly FULYZAQ)
PDF, 48 KB
PDF, 48 KB
Naglazyme (Medical)
PDF, 88 KB
PDF, 88 KB
Nasal Corticosteroids (azelastine HCl-fluticasone propionate (Dymista) | Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)
PDF, 184 KB
PDF, 184 KB
Natpara
PDF, 174 KB
PDF, 174 KB
Nayzilam | Valtoco
PDF, 164 KB
PDF, 164 KB
Neumega (Medical)
PDF, 38 KB
PDF, 38 KB
Neupro
PDF, 22 KB
PDF, 22 KB
Nexletol | Nexlizet
PDF, 77 KB
PDF, 77 KB
Nexviazyme (Medical)
PDF, 228 KB
PDF, 228 KB
Nocdurna
PDF, 161 KB
PDF, 161 KB
Noninfectious Uveitis (NIU) Drugs (Retisert | Yutiq) (Medical)
PDF, 231 KB
PDF, 231 KB
Non-Injectable Migraine Treatment (PREFERRED: Nurtec ODT | Qulipta) (Non-Preferred: Reyvow | Ubrelvy | Zavzpret)
PDF, 208 KB
PDF, 208 KB
Northera
PDF, 34 KB
PDF, 34 KB
Novarel | Pregnyl | Ovidrel | chorionic gonadotropin
PDF, 221 KB
PDF, 221 KB
Noxafil
PDF, 262 KB
PDF, 262 KB
Nplate (Medical)
PDF, 245 KB
PDF, 245 KB
Nucala - CRSWNP (Chronic Rhinosinusitis with Nasal Polyps) (Medical)
PDF, 196 KB
PDF, 196 KB
Nucala - CRSWNP (Chronic Rhinosinusitis with Nasal Polyps) (Pharmacy)
PDF, 196 KB
PDF, 196 KB
Nucala SQ - EGPA (Eosinophilic Granulomatosis Polyangiitis) (Medical)
PDF, 72 KB
PDF, 72 KB
Nucala SQ - EGPA (Eosinophilic Granulomatosis Polyangiitis) (Pharmacy)
PDF, 72 KB
PDF, 72 KB
Nucala SQ - HES (Hypereosinophilic Syndome) (Pharmacy)
PDF, 210 KB
PDF, 210 KB
Nucala SQ - SEA (Severe Eosinophilic Asthma) (Medical)
PDF, 209 KB
PDF, 209 KB
Nucala SQ - SEA (Severe Eosinophilic Asthma) (Pharmacy)
PDF, 245 KB
PDF, 245 KB
Nuedexta
PDF, 23 KB
PDF, 23 KB
Nulibry (Medical)
PDF, 236 KB
PDF, 236 KB
Nulibry (Pharmacy)
PDF, 234 KB
PDF, 234 KB
Nulojix (Medical)
PDF, 229 KB
PDF, 229 KB
Nuplazid
PDF, 180 KB
PDF, 180 KB
Ocaliva
PDF, 161 KB
PDF, 161 KB
Ocrevus (Medical)
PDF, 186 KB
PDF, 186 KB
Ocular Antihistamines (Alocril | Alomide | bepotastine besilate 1.5% (Bepreve) | Lastacaft | Zerviate)
PDF, 139 KB
PDF, 139 KB
Odactra House Dust Mite Allergen Extract
PDF, 169 KB
PDF, 169 KB
OFEV
PDF, 273 KB
PDF, 273 KB
Olumiant
PDF, 169 KB
PDF, 169 KB
Omisirge (Medical)
PDF, 228 KB
PDF, 228 KB
Ophthalmic Corticosteroid Injections (Ozurdex | Iluvien | Xipere) (Medical)
PDF, 232 KB
PDF, 232 KB
Opioids - Commercial Only
PDF, 239 KB
PDF, 239 KB
Opzelura
PDF, 146 KB
PDF, 146 KB
Oral Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
PDF, 157 KB
PDF, 157 KB
Oral PPI Drugs (Dexilant | omeprazole/sodium bicarbonate capsules | omeprazole/sodium bicarbonate powder packets)
PDF, 160 KB
PDF, 160 KB
Oralair
PDF, 36 KB
PDF, 36 KB
Orencia - Graft Versus Host Disease (GVHD) (Medical)
PDF, 205 KB
PDF, 205 KB
Orencia IV (Infusion only) (Medical)
PDF, 61 KB
PDF, 61 KB
Orencia SQ (Pharmacy)
PDF, 171 KB
PDF, 171 KB
Orfadin | Nityr | nitisinone
PDF, 166 KB
PDF, 166 KB
Orilissa
PDF, 185 KB
PDF, 185 KB
Orkambi
PDF, 195 KB
PDF, 195 KB
Osphena
PDF, 28 KB
PDF, 28 KB
Otezla
PDF, 182 KB
PDF, 182 KB
Otrexup | Rasuvo | Reditrex
PDF, 137 KB
PDF, 137 KB
Overactive Bladder Drugs (Gemtesa | Myrbetriq | Toviaz)
PDF, 163 KB
PDF, 163 KB
Oxbryta
PDF, 246 KB
PDF, 246 KB
Oxervate
PDF, 211 KB
PDF, 211 KB
Oxlumo
PDF, 171 KB
PDF, 171 KB
Palforzia
PDF, 206 KB
PDF, 206 KB
Palynziq Injection
PDF, 58 KB
PDF, 58 KB
Pancreatic Enzymes (Pancreaze | Pertzye | Viokace)
PDF, 28 KB
PDF, 28 KB
Pluvicto (Medical)
PDF, 227 KB
PDF, 227 KB
Pradaxa
PDF, 186 KB
PDF, 186 KB
Praluent | Repatha
PDF, 253 KB
PDF, 253 KB
Preferred Adalimumab Products (Cyltezo | Humira | Hyrimoz)
PDF, 239 KB
PDF, 239 KB
Pretomanid
PDF, 57 KB
PDF, 57 KB
Prevymis (Tablets) (Pharmacy benefit)
PDF, 196 KB
PDF, 196 KB
Prevymis IV (Medical)
PDF, 216 KB
PDF, 216 KB
Prialt (Medical)
PDF, 31 KB
PDF, 31 KB
Procysbi
PDF, 169 KB
PDF, 169 KB
Promacta
PDF, 233 KB
PDF, 233 KB
Prophylaxis Hereditary Angiodema Drugs (Medical) (Cinryze | Haegarda | Takhzyro)
PDF, 248 KB
PDF, 248 KB
Prophylaxis Hereditary Angiodema Drugs (Pharmacy) (Cinryze | Haegarda | Orladeyo | Takhzyro)
PDF, 204 KB
PDF, 204 KB
Pulmonary Arterial Hypertension Drugs (Medical) (sildenafil IV | epoprostenol IV | treprostinil IV | Uptravi IV)
PDF, 267 KB
PDF, 267 KB
Pulmonary Arterial Hypertension Drugs (Pharmacy) (sildenafil 20mg | sildenafil oral suspension | tadalafil 20mg | Tadliq | ambrisentan | bosentan | Opsumit | Tracleer | Adempas | Orenitram | Tyvaso | Tyvaso DPI | Uptravi | Ventavis)
PDF, 258 KB
PDF, 258 KB
Pulmozyme
PDF, 207 KB
PDF, 207 KB
Purified Cortrophin Gel | HP Acthar Gel (Infantile Spasms)
PDF, 172 KB
PDF, 172 KB
Purified Cortrophin Gel | HP Acthar Gel (Myositis)
PDF, 216 KB
PDF, 216 KB
Purified Cortrophin Gel | HP Acthar Gel (Nephrotic Syndrome)
PDF, 225 KB
PDF, 225 KB
Purified Cortrophin Gel | HP Acthar Gel (Ocular Diseases)
PDF, 227 KB
PDF, 227 KB
Purified Cortrophin Gel | HP Acthar Gel (Other Indications)
PDF, 202 KB
PDF, 202 KB
Purified Cortrophin Gel | HP Acthar Gel (Sarcoidosis)
PDF, 171 KB
PDF, 171 KB
Purified Cortrophin Gel | HP Acthar Gel (Systemic Lupus Erythematosus)
PDF, 223 KB
PDF, 223 KB
Pyrukynd
PDF, 183 KB
PDF, 183 KB
Qalsody
PDF, 210 KB
PDF, 210 KB
Qelbree
PDF, 154 KB
PDF, 154 KB
Radicava IV (Medical)
PDF, 87 KB
PDF, 87 KB
Radicava ORS
PDF, 192 KB
PDF, 192 KB
Ragwitek
PDF, 162 KB
PDF, 162 KB
Ravicti
PDF, 175 KB
PDF, 175 KB
Rayaldee
PDF, 191 KB
PDF, 191 KB
Reblozyl (Medical)
PDF, 92 KB
PDF, 92 KB
Rebyota (Medical)
PDF, 196 KB
PDF, 196 KB
Recombinant Growth Hormone (rhGH) (PREFERRED: Omnitrope | Norditropin) (NON-PREFERRED: Genotropin | Humatrope |Ngnela | Nutropin | Nutropin AQ | Saizen | Sogroya |Skytrofa | Zomacton)
PDF, 179 KB
PDF, 179 KB
Recorlev
PDF, 211 KB
PDF, 211 KB
Relyvrio
PDF, 181 KB
PDF, 181 KB
Revcovi (Pharmacy)
PDF, 94 KB
PDF, 94 KB
Rezurock
PDF, 161 KB
PDF, 161 KB
Rezzayo (Medical)
PDF, 193 KB
PDF, 193 KB
Riabni | Rituxan IV | Ruxience | Truxima (Medical) (Non-Preferred)
PDF, 263 KB
PDF, 263 KB
Rinvoq
PDF, 242 KB
PDF, 242 KB
Rituxan Hycela IV (Medical - Provided by Physician's office)
PDF, 99 KB
PDF, 99 KB
Rituxan IV - for Pemphigus Vulgaris (Medical) (Non-Preferred)
PDF, 99 KB
PDF, 99 KB
Roctavian (Medical)
PDF, 223 KB
PDF, 223 KB
Ruconest (Pharmacy)
PDF, 234 KB
PDF, 234 KB
Rukobia.pdf
PDF, 30 KB
PDF, 30 KB
Ryplazim (Medical)
PDF, 239 KB
PDF, 239 KB
Rystiggo (Medical)
PDF, 185 KB
PDF, 185 KB
Sabril | Vigadrone | vigabatrin
PDF, 169 KB
PDF, 169 KB
Saliva Substitutes (Aquoral | Caphosol | NeutraSal | SalivaMax | Salivate Rx)
PDF, 33 KB
PDF, 33 KB
Samsca
PDF, 40 KB
PDF, 40 KB
Saphnelo (Medical)
PDF, 250 KB
PDF, 250 KB
Savaysa
PDF, 175 KB
PDF, 175 KB
Savella
PDF, 156 KB
PDF, 156 KB
Scenesse (Medical)
PDF, 71 KB
PDF, 71 KB
Serostim
PDF, 159 KB
PDF, 159 KB
Seysara
PDF, 27 KB
PDF, 27 KB
SGLT2 (Brenzavvy| Invokana | Invokamet/XR | Qtern | Segluromet | Steglatro | Steguljan|Segluromet)
PDF, 163 KB
PDF, 163 KB
Siliq Injection (Pharmacy)
PDF, 163 KB
PDF, 163 KB
Simponi SQ (Pharmacy benefit only)
PDF, 174 KB
PDF, 174 KB
Simponi® ARIA™ IV (Medical only) (Non-Preferred)
PDF, 222 KB
PDF, 222 KB
Sinuva Sinus Implant (Medical)
PDF, 202 KB
PDF, 202 KB
Sirturo
PDF, 158 KB
PDF, 158 KB
Skyclarys
PDF, 196 KB
PDF, 196 KB
Skyrizi - Crohn's Disease (CD) (Pharmacy)
PDF, 170 KB
PDF, 170 KB
Skyrizi - Plaque Psoriasis & Psoriatic Arthritis (PsO & PsA) (Pharmacy)
PDF, 142 KB
PDF, 142 KB
Skysona (Medical)
PDF, 238 KB
PDF, 238 KB
Sodium Oxbate Products (Lumryz | Sodium Oxbate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 233 KB
PDF, 233 KB
Sodium Phenylbutyrate Products (sodium phenylbutyrate (Buphenyl) | Olpruva | Pheburane)
PDF, 162 KB
PDF, 162 KB
Soliqua | Xultophy
PDF, 193 KB
PDF, 193 KB
Soliris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
PDF, 100 KB
PDF, 100 KB
Soliris IV - Generalized Myasthenia Gravis (gMG) (Medical)
PDF, 237 KB
PDF, 237 KB
Soliris IV-Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)
PDF, 257 KB
PDF, 257 KB
Soliris IV-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
PDF, 99 KB
PDF, 99 KB
Somatostatin Analog Drugs (Bynfezia | Mycapssa | Sandostatin LAR Depot | Signafor | Somavert) (Pharmacy)
PDF, 210 KB
PDF, 210 KB
Somatostatin Analog Drugs (lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection | Somatuline Depot injection) (Medical)
PDF, 181 KB
PDF, 181 KB
Sotyktu
PDF, 168 KB
PDF, 168 KB
Spevigo (Medical)
PDF, 208 KB
PDF, 208 KB
Spinraza (Medical - provided by Physician's office)
PDF, 147 KB
PDF, 147 KB
Spravato (Medical - Behavioral Health)
PDF, 186 KB
PDF, 186 KB
Stadol Nasal Spray
PDF, 27 KB
PDF, 27 KB
Stelara - Crohn's Disease & Ulcerative Colitis (CD & UC) (Pharmacy)
PDF, 198 KB
PDF, 198 KB
Stelara - Plaque Psoriasis & Psoriatic Arthritis (PsO & PsA) (Pharmacy)
PDF, 178 KB
PDF, 178 KB
Stendra | vardenafil (Levitra)
PDF, 27 KB
PDF, 27 KB
Strensiq
PDF, 70 KB
PDF, 70 KB
Sublocade ER (buprenorphine extended release) (MEDICARE PART B ONLY)
PDF, 103 KB
PDF, 103 KB
Sucraid
PDF, 34 KB
PDF, 34 KB
Sunlenca
PDF, 215 KB
PDF, 215 KB
Sunosi
PDF, 191 KB
PDF, 191 KB
Syfovre
PDF, 189 KB
PDF, 189 KB
Symdeko
PDF, 228 KB
PDF, 228 KB
Synagis (PASynagis)
PDF, 894 KB
PDF, 894 KB
Syndros Oral Solution
PDF, 68 KB
PDF, 68 KB
Taltz SQ
PDF, 227 KB
PDF, 227 KB
Tarpeyo
PDF, 197 KB
PDF, 197 KB
tasimelteon (Hetlioz)
PDF, 205 KB
PDF, 205 KB
Tavalisse
PDF, 245 KB
PDF, 245 KB
Tavneos
PDF, 192 KB
PDF, 192 KB
Tecartus (Medical)
PDF, 239 KB
PDF, 239 KB
Tegsedi SQ Injection (Medical)
PDF, 68 KB
PDF, 68 KB
Tepezza (Medical)
PDF, 219 KB
PDF, 219 KB
Testosterone (Pharmacy) (PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution | Kyzatrex) (NON-PREFERRED - Androderm | Natesto | Vogelxo 1% | Xyosted injection)
PDF, 218 KB
PDF, 218 KB
Tezspire (Medical)
PDF, 244 KB
PDF, 244 KB
Tezspire (Pharmacy)
PDF, 233 KB
PDF, 233 KB
Thiola | Thiola EC
PDF, 74 KB
PDF, 74 KB
Tiglutik
PDF, 155 KB
PDF, 155 KB
Tobi Podhaler
PDF, 27 KB
PDF, 27 KB
Topical Acne Drugs (PREFERRED: adapalene (generic Differin) | tretinoin (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel | Altreno | Aklief | Amzeeq | Azelex | clindamycin1.2%/benzoyl peroxide 2.5% | dapsone gel 5% | Fabior | Retin-A Micro | tazarotene cream 0.1% | tretinoin gel 0.05% | tretinoin microsphere | Winlevi)
PDF, 152 KB
PDF, 152 KB
Topical Antibiotics (Altabax | Xepi)
PDF, 139 KB
PDF, 139 KB
Topical Antifungals (Ertaczo | luliconazole | Mentax | naftifine | Naftin | oxiconazole | sulconazole)
PDF, 149 KB
PDF, 149 KB
Topical Corticosteroids (amcinonide 0.1% | betamethasone valerate 0.12% foam | calcipotriene/betamethasone | Capex Shampoo | clobetasol proprionate | clocortolone pivalate | Cordran Tape | dexoximetasone 0.05% and 0.25% | diflorasone 0.05% | fluocinonide 0.1% cream | flurandrenolide 0.05% | fluticasone 0.05% | Impoyz | Texacort | triamcinolone spray)
PDF, 170 KB
PDF, 170 KB
Topical Immunomodulators (Zyclara | imiquimod 3.75% packets/pump | Picato | Klisyri)
PDF, 183 KB
PDF, 183 KB
Topical Psoriasis Medications (Vtama | Zoryve)
PDF, 170 KB
PDF, 170 KB
Topical Rosacea Drugs (Mirvaso | Rhofade | Soolantra | Zilxi)
PDF, 163 KB
PDF, 163 KB
Tremfya
PDF, 143 KB
PDF, 143 KB
Trikafta
PDF, 198 KB
PDF, 198 KB
Trogarzo IV (Medical) (Medication will be provided by the Physician's office.)
PDF, 35 KB
PDF, 35 KB
Tysabri IV (Medical)
PDF, 205 KB
PDF, 205 KB
Tyvaso (PH-ILD)
PDF, 198 KB
PDF, 198 KB
Uloric
PDF, 27 KB
PDF, 27 KB
Ultomiris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
PDF, 119 KB
PDF, 119 KB
Ultomiris IV - Generalized Myasthenia Gravis (gMG) (Medical)
PDF, 237 KB
PDF, 237 KB
Ultomiris IV-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
PDF, 240 KB
PDF, 240 KB
Uplinza (Medical)
PDF, 226 KB
PDF, 226 KB
Upneeq
PDF, 205 KB
PDF, 205 KB
Valcyte
PDF, 31 KB
PDF, 31 KB
Vascepa
PDF, 196 KB
PDF, 196 KB
Vecamyl (Open Commercial Formulary Only)
PDF, 23 KB
PDF, 23 KB
Vemlidy
PDF, 170 KB
PDF, 170 KB
Veozah
PDF, 156 KB
PDF, 156 KB
Verquvo
PDF, 160 KB
PDF, 160 KB
Vijoice
PDF, 185 KB
PDF, 185 KB
Vimizim IV (Medical) (IV Infusion performed ONLY at Sentara Infusion Centers.)
PDF, 68 KB
PDF, 68 KB
Visudyne (Medical)
PDF, 202 KB
PDF, 202 KB
Vivjoa
PDF, 226 KB
PDF, 226 KB
Vowst
PDF, 200 KB
PDF, 200 KB
Voxzogo
PDF, 197 KB
PDF, 197 KB
Vtama
PDF, 151 KB
PDF, 151 KB
Vyepti (Medical)
PDF, 64 KB
PDF, 64 KB
Vyjuvek (Medical)
PDF, 224 KB
PDF, 224 KB
Vyleesi
PDF, 153 KB
PDF, 153 KB
Vyndaqel | Vyndamax
PDF, 33 KB
PDF, 33 KB
Vyvanse (Binge Eating Disorder)
PDF, 185 KB
PDF, 185 KB
Vyvgart (Medical)
PDF, 222 KB
PDF, 222 KB
Wakix
PDF, 215 KB
PDF, 215 KB
Weight Management Drugs (benzphetamine | Contrave | diethylpropion IR/ER | Lomaira | phendimetrazine IR | phentermine HCL | Qsymia | Saxenda | Xenical | Wegovy) Group Specific Benefit
PDF, 146 KB
PDF, 146 KB
Xadago
PDF, 135 KB
PDF, 135 KB
Xdemvy
PDF, 156 KB
PDF, 156 KB
Xeljanz | Xeljanz XR
PDF, 209 KB
PDF, 209 KB
Xenazine, tetrabenazine
PDF, 51 KB
PDF, 51 KB
Xenleta (Medical)
PDF, 59 KB
PDF, 59 KB
Xenleta (Pharmacy)
PDF, 139 KB
PDF, 139 KB
Xenpozyme (Medical)
PDF, 237 KB
PDF, 237 KB
Xiaflex (Medical)
PDF, 203 KB
PDF, 203 KB
Xifaxan
PDF, 180 KB
PDF, 180 KB
Xofigo (Medical)
PDF, 229 KB
PDF, 229 KB
Xolair (Medical)
PDF, 459 KB
PDF, 459 KB
Xolair (Pharmacy)
PDF, 451 KB
PDF, 451 KB
Ycanth (Medical)
PDF, 170 KB
PDF, 170 KB
Yescarta (Medical)
PDF, 229 KB
PDF, 229 KB
Zeposia
PDF, 147 KB
PDF, 147 KB
Zevalin (Medical)
PDF, 247 KB
PDF, 247 KB
Zinplava (Medical)
PDF, 234 KB
PDF, 234 KB
Zokinvy
PDF, 194 KB
PDF, 194 KB
Zolgensma IV (Medical)
PDF, 220 KB
PDF, 220 KB
Zomig Nasal Spray
PDF, 29 KB
PDF, 29 KB
Zontivity
PDF, 28 KB
PDF, 28 KB
Zorbtive
PDF, 59 KB
PDF, 59 KB
Ztalmy
PDF, 141 KB
PDF, 141 KB
Zulresso Injection (Behavioral Health Medical)
PDF, 189 KB
PDF, 189 KB
Zyflo | Zileuton ER
PDF, 25 KB
PDF, 25 KB
Zynteglo (Medical)
PDF, 240 KB
PDF, 240 KB