PA - Prior Authorization Forms
(click column headers to sort)Listed below are all the PA forms you will need in order to request drugs that require prior authorization.
To submit a request:
- Select and print the proper form from the list below
- Fill out the form completely
- Fax the completed form to us at 1-888-879-6938
(Please note - If the PA form asks for supporting medical documentation, please fax this information along with the completed PA form.)
The forms are provided here in MS Word. If you cannot view a file, please download the appropriate free plug-in from the links below.
- MS Word Viewer (.doc or .rtf)
- MS Excel Viewer (.xls)
- Acrobat Viewer (.pdf)
| Name | Description | Date |
Acute Migraine
270 kB
|
#10110 | 11/6/2007 |
|
Amevive
65 kB
|
#20910 | 11/6/2007 |
|
Antifungals
198 kB
|
#10120 | 1/17/2008 |
|
Botox - Myobloc
87 kB
|
#10210 | 2/27/2008 |
|
Brand Drugs
109 kB
|
#10220 | 11/6/2007 |
|
Byetta
68 kB
|
#10230 | 1/2/2008 |
|
Cox II Inhibitors
62 kB
|
#10310 | 11/6/2007 |
|
Dosage Strength
29 kB
|
#10410 | 10/5/2005 |
|
Dose Consolidation
66 kB
|
#10420 | 11/6/2007 |
|
Drug Drug Interactions
31 kB
|
#10400 | 11/22/2006 |
|
EPO
72 kB
|
#10520 | 11/6/2007 |
|
Flumist
39 kB
|
#10610 | 2/21/2008 |
|
Four (4) Brand PA Form
68 kB
|
#10600 | 11/6/2007 |
|
Fuzeon
32 kB
|
#10620 | 10/5/2005 |
|
Growth Hormone
119 kB
|
#10710 | 1/17/2008 |
Med Watch Form
144 kB
|
12/22/2004 | |
|
Miscellaneous Non Preferred
62 kB
|
#20420 | 11/6/2007 |
|
MS Agents
141 kB
|
#20430 | 4/17/2008 |
|
Multi Antipsychotic - Clinical PA
67 kB
|
#20440 | 11/6/2007 |
|
Narcotics
118 kB
|
#20510 | 10/25/2007 |
|
Neupogen Leukine
34 kB
|
#20520 | 10/5/2005 |
|
Non Sedating Antihistamines
63 kB
|
#20530 | 11/6/2007 |
|
Ondansetron
37 kB
|
#20610 | 10/12/2007 |
|
Oral Anabolic Steroid
63 kB
|
#20600 | 1/17/2008 |
|
Part D Safety Net
30 kB
|
#20740 | 11/6/2007 |
|
Provigil
68 kB
|
#20710 | 11/6/2007 |
|
Remicade/Kineret
129 kB
|
#10510 | 11/6/2007 |
|
Sedative Hypnotics
129 kB
|
#30110 | 11/6/2007 |
|
Sensipar
65 kB
|
#30115 | 11/6/2007 |
|
Subjective Global Assessment (SGA)
26 kB
|
10/5/2005 | |
|
Symlin
78 kB
|
#301501 | 11/6/2007 |
|
Synagis Respigam
113 kB
|
#30120 | 11/15/2007 |
|
Synvisc
74 kB
|
#30130 | 2/27/2008 |
|
Syringe Filling
29 kB
|
#30140 | 10/5/2005 |
|
Vivitrol
65 kB
|
#3400 | 1/2/2007 |
|
Zyvox
100 kB
|
#30820 | 1/2/2008 |
