General Drug Prior Authorization Forms

The prescription forms center contains tools that may be necessary for filing certain claims, appealing claims, changing information about your office or receiving authorization for certain prescriptions.
Document Title Document Type Document Size Last Updated
A
Abraxane PDF 71kB 08/14/2020
Actemra PDF 93kB 01/25/2021
Acthar HP PDF 59kB 05/11/2020
Actimmune PDF 64kB 05/11/2020
Adakveo PDF 85kB 05/14/2021
Adcetris PDF 89kB 05/14/2021
Adrucil PDF 62kB 08/14/2020
Akynzeo PDF 57kB 11/26/2019
Aldurazyme PDF 58kB 11/26/2019
Aliqopa PDF 58kB 08/14/2020
Aloxi PDF 62kB 02/05/2020
Alimta PDF 72kB 05/14/2021
Amondys 45, Exondys 51, Viltepso, Vyondys 53 PDF 83kB 07/14/2021
Ampyra PDF 61kB 11/20/2020
Anzemet PDF 56kB 11/26/2019
Aralast, Glassia, Prolastin, Zemaira PDF 76kB 11/26/2019
Aranesp, Epogen, Mircera, Procrit, Retacrit PDF 92kB 05/11/2020
Arcalyst PDF 65kB 07/14/2021
Arranon PDF 58kB 08/26/2019
Asparlas PDF 58kB 08/14/2020
Austedo PDF 61kB 10/11/2019
Avastin PDF 86kB 05/14/2021
Avycaz PDF 58kB 08/26/2019
Avsola, Inflectra, Remicade, Renflexis PDF 112kB 07/14/2021
B
Bavencio PDF 61kB 11/20/2020
Beleodaq PDF 60kB 08/14/2020
Bendeka, Treanda PDF 91kB 11/26/2019
Benlysta PDF 71kB 05/14/2021
Beovu, Eylea, Lucentis, Macugen PDF 62kB 03/22/2021
Berinert, Cinryze, Firazyr, Kalbitor, Ruconest PDF 99kB 08/14/2020
Besponsa PDF 54kB 08/26/2019
Blenrep PDF 60kB 11/20/2020
Bleomycin PDF 56kB 11/26/2019
Botox PDF 104kB 05/14/2021
Braftovi PDF 61kB 11/20/2020
Brineura PDF 80kB 05/11/2020
Bynfezia, Sandostatin, Sandostatin LAR PDF 373kB 09/29/2021
Bethkis, Cayston, Kitabis Pak, TOBI, TOBI Podhaler PDF 92kB 11/20/2020
C
Cabenuva PDF 89kB 07/14/2021
Cablivi PDF 62kB 07/14/2021
Carboplatin PDF 65kB 02/05/2020
Ceprotin PDF 85kB 11/20/2020
Cerdelga PDF 57kB 08/26/2019
Cerezyme, Elelyso, VPRIV PDF 64kB 07/28/2021
CGRP Inhibitors PDF 67kB 09/13/2021
Cholbam PDF 63kB 05/11/2020
Cimzia PDF 113kB 08/19/2021
Cisplatin PDF 65kB 08/14/2020
Cosela PDF 66kB 06/10/2021
Crysvita PDF 265kB 11/22/2021
Cyramza PDF 65kB 08/14/2020
Cytarabine PDF 63kB 08/14/2020
D
Dacarbazine PDF 60kB 03/22/2021
Danyelza PDF 81kB 03/22/2021
Darzalex PDF 94kB 06/10/2021
Daunorubicin PDF 55kB 11/26/2019
Diacomit PDF 55kB 11/26/2019
Duopa PDF 85kB 08/14/2020
Dupixent PDF 94kB 11/26/2019
Durysta PDF 65kB 09/13/2021
E
Egrifta PDF 61kB 02/05/2020
Elaprase PDF 81kB 11/26/2019
Eligard PDF 61kB 07/14/2021
Emend, Cinvanti PDF 66kB 03/22/2021
Emflaza PDF 55kB 11/26/2019
Empliciti, Ninlaro PDF 61kB 08/14/2020
Enhertu PDF 85kB 05/14/2021
Enspryng PDF 68kB 11/20/2020
Entyvio PDF 67kB 01/25/2021
Epidiolex PDF 63kB 11/20/2020
Erbitux PDF 83kB 11/26/2019
Erleada, Nubeqa PDF 58kB 08/14/2020
Erwinase PDF 275kB 09/29/2021
Etopophos, Toposar PDF 65kB 08/14/2020
Evenity PDF 85kB 07/28/2021
Evkeeza PDF 68kB 09/13/2021
Evomela PDF 55kB 11/26/2019
Evrysdi PDF 84kB 11/20/2020
F
Fabrazyme PDF 57kB 11/26/2019
Fasenra PDF 78kB 11/26/2019
Faslodex PDF 63kB 07/14/2021
Fertility PDF 67kB 05/11/2020
Floxuridine PDF 57kB 08/14/2020
G
Gamifant PDF 87kB 05/14/2021
Gattex PDF 60kB 08/14/2020
Gazyva PDF 64kB 08/14/2020
Gemzar PDF 64kB 08/14/2020
General Injectables PDF 57kB 08/26/2019
General Medication Prior Authorization PDF 58kB 08/26/2019
Givlaari PDF 62kB 03/22/2021
Glucose Monitoring Supplies PDF 63kB 08/19/2021
Granix, Neupogen, Nivestym PDF 66kB 07/14/2021
Growth Hormones PDF 88kB 11/20/2020
H
Halaven PDF 62kB 02/05/2020
Hemlibra PDF 57kB 11/26/2019
Hemophilia Factor PDF 85kB 03/22/2021
Hepatitis PDF 95kB 11/20/2020
Herceptin, Hylecta PDF 65kB 07/14/2021
Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera PDF 68kB 07/14/2021
Hyaluronic Acid Drugs PDF 65kB 08/14/2020
Hycamtin IV PDF 73kB 11/26/2019
I
Idhifa PDF 53kB 08/26/2019
Idiopathic Pulmonary Fibrosis Therapy PDF 62kB 08/14/2020
Ilaris PDF 66kB 11/20/2020
Ilumya PDF 74kB 01/25/2021
Imfinzi PDF 64kB 05/14/2021
Imlygic PDF 55kB 11/26/2019
Increlex PDF 61kB 08/14/2020
Infugem PDF 58kB 08/26/2019
Inrebic PDF 55kB 11/26/2019
Iron Chelating Agents PDF 65kB 11/20/2020
Intravenous Immune Globulin (IVIG) -SCIG PDF 198kB 03/22/2021
J
Jelmyto PDF 60kB 08/14/2020
Jemperli PDF 53kB 06/10/2021
Jetrea PDF 59kB 08/14/2020
Jevtana PDF 55kB 11/26/2019
Juxtapid PDF 135kB 02/05/2020
K
Kadcyla PDF 64kB 05/14/2021
Kalydeco PDF 86kB 11/20/2020
Kanuma PDF 57kB 11/26/2019
Kevzara PDF 61kB 11/26/2019
Keytruda PDF 97kB 07/28/2021
Khapzory PDF 63kB 08/14/2020
Kineret PDF 69kB 08/14/2020
Korlym PDF 59kB 02/05/2020
Krystexxa PDF 83kB 11/20/2020
Kuvan PDF 60kB 11/18/2019
Kyprolis PDF 61kB 03/22/2021
L
Lartruvo PDF 58kB 11/26/2019
Levorphanol PDF 67kB 11/20/2020
Libtayo PDF 62kB 06/10/2021
Lumizyme PDF 57kB 11/26/2019
Lumoxiti PDF 59kB 08/14/2020
Lupron Depot, Lupron Depot-PED, Lupaneta, Fensolvi, Firmagon, Supprelin LA, Triptodur, Vantas PDF 71kB 07/28/2021
M
Macrilen PDF 52kB 08/26/2019
Makena PDF 64kB 05/11/2020
Mektovi PDF 57kB 11/20/2020
Margenza PDF 62kB 05/14/2021
Marqibo PDF 56kB 11/26/2019
Mepsevii PDF 56kB 11/26/2019
Mozobil PDF 55kB 11/26/2019
Monjuvi PDF 63kB 03/22/2021
Multiple Sclerosis PDF 99kB 11/20/2020
Mylotarg PDF 60kB 11/20/2020
Myobloc, Dysport, Xeomin PDF 68kB 02/05/2020
N
Naglazyme PDF 57kB 11/26/2019
Nerlynx PDF 60kB 11/20/2020
Nipent PDF 61kB 08/14/2020
Nplate PDF 66kB 09/29/2021
Nucala, Cinqair PDF 97kB 03/22/2021
Nulibry PDF 54kB 06/10/2021
O
Ocaliva PDF 58kB 08/26/2019
Ohio Opioid Fax PDF 95kB 05/11/2020
Onivyde PDF 56kB 11/26/2019
Onpattro, Tegsedi PDF 63kB 08/14/2020
Opdivo PDF 81kB 09/13/2021
Opioids PDF 81kB 11/20/2020
Oral Fentanyl PDF 59kB 08/14/2020
Orencia PDF 90kB 01/25/2021
Orkambi PDF 62kB 11/20/2020
Oxaliplatin PDF 62kB 08/14/2020
Oxervate PDF 61kb 11/20/2020
Oxlumo PDF 80kB 03/22/2021
P
Paclitaxel PDF 64kB 02/05/2020
PAH Therapy PDF 66kB 11/26/2019
Padcev PDF 62kB 09/29/2021
Palynziq PDF 59kB 11/26/2019
Parsabiv PDF 59kB 02/05/2020
Pegfilgrastim PDF 93kB 07/14/2021
Pepaxto PDF 84kB 05/14/2021
Perjeta PDF 67kB 05/14/2021
Phesgo PDF 63kB 05/14/2021
Piqray PDF 79kB 11/26/2019
Polivy PDF 62kb 11/20/2020
Portrazza PDF 56kB 11/26/2019
Poteligeo PDF 60kB 08/14/2020
Praluent PDF 93kB 02/05/2020
Probuphine PDF 57kB 11/26/2019
Procysbi PDF 58kB 08/14/2020
Proleukin PDF 55kB 11/26/2019
Prolia PDF 92kB 02/05/2020
Promacta PDF 85kB 08/19/2021
Provenge PDF 60kB 08/14/2020
R
Radicava PDF 63kB 07/28/2021
Reblozyl PDF 86kB 05/14/2021
Revcovi PDF 89kB 08/14/2020
Rinvoq PDF 65kB 10/11/2019
Rituxan, Ruxience, Truxima PDF 168kB 03/22/2021
Rituxan Hycela PDF 70kB 06/10/2021
Rozlytrek PDF 57kB 11/26/2019
Rybrevant PDF 61kB 07/14/2021
Rylaze PDF 62kB 09/13/2021
S
Sarclisa PDF 63kB 06/10/2021
Scenesse PDF 61kB 08/14/2020
Signifor LAR PDF 324kB 09/29/2021
Siliq PDF 61kB 11/26/2019
Simponi PDF 93kB 01/25/2021
Skyrizi PDF 60kB 11/26/2019
Soliris PDF 73kB 09/29/2021
Somatuline Depot PDF 63kB 08/14/2020
Spinraza PDF 90kB 11/20/2020
Spravato PDF 67kB 09/13/2021
Stelara SQ PDF 76kB 01/25/2021
Stelara IV PDF 66kB 01/25/2021
Strensiq PDF 58kB 11/26/2019
Sublingual Allergen Immunotherapy PDF 64kB 05/11/2020
Sucraid PDF 81kB 08/26/2019
Sunosi, Wakix PDF 67kB 05/11/2020
Sustol PDF 57kB 11/26/2019
Sylatron PDF 77kB 08/26/2019
Symdeko PDF 84kB 11/20/2020
Sylvant PDF 55kB 11/26/2019
Synagis PDF 94kB 11/26/2019
T
Taltz PDF 71kB 08/14/2020
Taxotere PDF 57kB 11/26/2019
Tecentriq PDF 92kB 06/10/2021
Temodar IV PDF 62kB 11/26/2019
Tepezza PDF 63kB 06/10/2021
Testopel PDF 63kB 08/14/2020
Testosterone Therapy PDF 92kB 08/14/2020
Tivdak PDF 277kB 11/22/2021
Trelstar PDF 60kB 07/14/2021
Trikafta PDF 63kB 11/20/2020
Trisenox PDF 56kB 11/26/2019
Trodelvy PDF 62kB 06/10/2021
Trogarzo PDF 56kB 08/26/2019
Tymlos PDF 61kB 11/20/2020
Tysabri PDF 72kB 01/25/2021
U
Ultomiris PDF 67kB 09/29/2021
Unituxin PDF 60kB 08/14/2020
Uplizna PDF 62kB 01/25/2021
V
Vectibix PDF 55kB 11/26/2019
Velcade PDF 63kB 05/14/2021
Vimizim PDF 57kB 11/26/2019
Vincasar PFS PDF 65kB 08/14/2020
Vitrakvi PDF 53kB 08/26/2019
Vyndamax, Vyndaqel PDF 63kB 08/14/2020
Vyxeos PDF 59kB 08/14/2020
X
Xgeva PDF 83kB 11/26/2019
Xiaflex PDF 62kB 07/14/2021
Xofigo PDF 60kB 08/14/2020
Xolair PDF 68kB 05/11/2020
Xyrem PDF 62kB 08/14/2020
Y
Yervoy PDF 119kB 03/22/2021
Yondelis PDF 83kB 03/22/2021
Z
Zaltrap PDF 56kB 11/26/2019
Zavesca PDF 56kB 08/26/2019
Zepzelca PDF 60kB 05/14/2021
Zilretta PDF 59kB 08/14/2020
Zoladex PDF 60kB 07/28/2021
Zulresso PDF 60kB 08/14/2020
Zynlonta PDF 51kB 06/10/2021