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 295kB 06/13/2022
Actemra PDF 320kB 12/27/2021
Acthar HP PDF 59kB 05/11/2020
Actimmune PDF 64kB 05/11/2020
Adakveo PDF 288kB 12/27/2021
Adcetris PDF 89kB 05/14/2021
Adrucil PDF 62kB 08/14/2020
Akynzeo PDF 57kB 11/26/2019
Aldurazyme PDF 287kB 12/27/2021
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 286kB 12/27/2021
Ampyra PDF 61kB 11/20/2020
Anzemet PDF 56kB 11/26/2019
Apretude PDF 299kB 03/25/2022
Aralast NP, Glassia, Prolastin C, Zemaira PDF 294kB 06/13/2022
Aranesp, Epogen, Procrit, Retacrit PDF 310kB 02/09/2022
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 470kB 06/13/2022
Avycaz PDF 58kB 08/26/2019
Avsola, Inflectra, Remicade, Renflexis PDF 331kB 02/09/2022
B
BAL in Oil, Edetate Calcium Disodium PDF 277kB 12/27/2021
Bavencio PDF 258kB 04/21/2022
Beleodaq PDF 60kB 08/14/2020
Bendeka, Treanda PDF 91kB 11/26/2019
Benlysta PDF 295kB 12/27/2021
Beovu, Eylea, Lucentis, Macugen PDF 265kB 06/13/2022
Berinert, Cinryze, Firazyr, Kalibitor, Ruconest PDF 336kB 02/09/2022
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 403kB 04/07/2022
Bethkis, Cayston, Kitabis Pak, TOBI, TOBI Podhaler PDF 92kB 11/20/2020
C
Cabenuva PDF 314kB 12/27/2021
Cablivi PDF 289kB 12/27/2021
Carboplatin PDF 65kB 02/05/2020
Ceprotin PDF 279kB 03/21/2022
Cerdelga PDF 57kB 08/26/2019
Cerezyme, Elelyso, VPRIV PDF 281kB 12/27/2021
CGRP Inhibitors PDF 67kB 09/13/2021
Cholbam PDF 63kB 05/11/2020
Cimzia PDF 352kB 05/09/2022
Cisplatin PDF 65kB 08/14/2020
Copaxone, Glatiramer, Glatopa PDF 276kB 02/09/2022
Cosela PDF 66kB 06/10/2021
Crysvita PDF 288kB 12/27/2021
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 287kB 02/09/2022
Dupixent PDF 94kB 11/26/2019
Durysta PDF 65kB 09/13/2021
E
Egrifta PDF 61kB 02/05/2020
Elaprase PDF 311kB 12/27/2021
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
Enjaymo PDF 289kB 05/18/2022
Enspryng PDF 68kB 11/20/2020
Entyvio PDF 289kB 02/09/2022
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 285kB 02/09/2022
Evkeeza PDF 307kB 05/18/2022
Evomela PDF 55kB 11/26/2019
Evrysdi PDF 84kB 11/20/2020
F
Fabrazyme PDF 282kB 05/18/2022
Fasenra PDF 303kB 12/27/2021
Faslodex PDF 63kB 07/14/2021
Feraheme, Injectafer, Monoferric PDF 272kB 06/13/2022
Fertility PDF 271kB 05/18/2022
Floxuridine PDF 57kB 08/14/2020
G
Gamifant PDF 299kB 05/18/2022
Gattex PDF 60kB 08/14/2020
Gazyva PDF 64kB 08/14/2020
Gemzar PDF 281kB 02/09/2022
General Injectables PDF 57kB 08/26/2019
General Medication Prior Authorization PDF 58kB 08/26/2019
Givlaari PDF 287kB 06/13/2022
Glucose Monitoring Supplies PDF 266kB 04/07/2022
Granix, Neupogen, Nivestym, Releuko PDF 274kB 05/18/2022
Growth Hormones PDF 314kB 04/21/2022
H
Halaven PDF 62kB 02/05/2020
Hemlibra PDF 57kB 11/26/2019
Hemophilia Factor PDF 327kB 03/10/2022
Hepatitis PDF 294kB 02/09/2022
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 309kB 06/13/2022
Ilumya PDF 300kB 03/21/2022
Imfinzi PDF 64kB 05/14/2021
Imlygic PDF 55kB 11/26/2019
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 452kB 03/21/2022
J
Jelmyto PDF 60kB 08/14/2020
Jemperli PDF 284kB 12/27/2021
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 281kB 12/27/2021
Kevzara PDF 61kB 11/26/2019
Keytruda PDF 100kB 06/13/2022
Khapzory PDF 63kB 08/14/2020
Kimmtrak PDF 267kB 05/09/2022
Kineret PDF 69kB 08/14/2020
Korlym PDF 59kB 02/05/2020
Krystexxa PDF 304kB 12/27/2021
Kuvan PDF 60kB 11/18/2019
Kyprolis PDF 61kB 03/22/2021
L
Lartruvo PDF 58kB 11/26/2019
Lemtrada PDF 294kB 02/09/2022
Levorphanol PDF 67kB 11/20/2020
Leqvio PDF 289kB 03/21/2022
Libtayo PDF 62kB 06/10/2021
Lumizyme PDF 279kB 12/27/2021
Lumoxiti PDF 59kB 08/14/2020
Lupron Depot, Lupron Depot-PED, Lupaneta, Fensolvi, Firmagon, Supprelin LA, Triptodur, Vantas PDF 342kB 05/09/2022
M
Macrilen PDF 52kB 08/26/2019
Makena PDF 257kB 03/21/2022
Mektovi PDF 57kB 11/20/2020
Margenza PDF 62kB 05/14/2021
Marqibo PDF 56kB 11/26/2019
Mepsevii PDF 279kB 12/27/2021
Mircera PDF 277kB 02/09/2022
Mozobil PDF 55kB 11/26/2019
Monjuvi PDF 63kB 03/22/2021
Multiple Sclerosis PDF 285kB 02/09/2022
Mvasi, Zirabev PDF 101kB 06/13/2022
Mylotarg PDF 60kB 11/20/2020
Myobloc, Dysport, Xeomin PDF 68kB 02/05/2020
N
Naglazyme PDF 280kB 12/27/2021
Nerlynx PDF 60kB 11/20/2020
Nexviazyme PDF 68kB 12/27/2021
Nipent PDF 61kB 08/14/2020
Nplate PDF 285kB 12/27/2021
Nucala, Cinqair PDF 327kB 12/27/2021
Nulojix PDF 271kB 02/09/2022
Nulibry PDF 288kB 12/27/2021
O
Ocaliva PDF 58kB 08/26/2019
Ocrevus PDF 267kB 02/09/2022
Ohio Opioid Fax PDF 95kB 05/11/2020
Onivyde PDF 56kB 11/26/2019
Onpattro PDF 283kB 06/22/2022
Opdivo PDF 568kB 06/13/2022
Opioids PDF 81kB 11/20/2020
Oral Fentanyl PDF 59kB 08/14/2020
Orencia PDF 284kB 04/07/2022
Orkambi PDF 62kB 11/20/2020
Oxaliplatin PDF 62kB 08/14/2020
Oxervate PDF 61kb 11/20/2020
Oxlumo PDF 309kB 12/27/2021
P
Paclitaxel PDF 64kB 02/05/2020
PAH Therapy PDF 275kB 02/09/2022
Padcev PDF 62kB 09/29/2021
Palynziq PDF 59kB 11/26/2019
Parsabiv PDF 59kB 02/05/2020
Pegfilgrastim PDF 309kB 12/27/2021
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 269 02/09/2022
Promacta PDF 85kB 08/19/2021
Provenge PDF 60kB 08/14/2020
R
Radicava PDF 282kB 12/27/2021
Reblozyl PDF 311kB 05/18/2022
Revcovi PDF 303kB 05/18/2022
Rinvoq PDF 65kB 10/11/2019
Riabni, Rituxan, Ruxience, Truxima PDF 332kB 03/10/2022
Rituxan Hycela PDF 70kB 06/10/2021
Rozlytrek PDF 57kB 11/26/2019
Rybrevant PDF 61kB 07/14/2021
Ryplazim PDF 283kB 03/21/2022
Rylaze PDF 62kB 09/13/2021
S
Saphnelo PDF 337kB 05/09/2022
Sarclisa PDF 63kB 06/10/2021
Scenesse PDF 61kB 08/14/2020
Signifor LAR PDF 350kB 12/27/2021
Siliq PDF 61kB 11/26/2019
Simponi PDF 313kB 12/27/2021
Skyrizi PDF 60kB 11/26/2019
Soliris PDF 292kB 12/27/2021
Somatuline Depot PDF 307kB 04/07/2022
Somavert PDF 279kB 02/09/2022
Spinraza PDF 304kB 12/27/2021
Spravato PDF 67kB 09/13/2021
Stelara SQ PDF 525kB 03/21/2022
Stelara IV PDF 285kB 03/21/2022
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 330kB 03/21/2022
T
Taltz PDF 71kB 08/14/2020
Taxotere PDF 57kB 11/26/2019
Tecentriq PDF 311kB 03/10/2022
Temodar IV PDF 62kB 11/26/2019
Tepezza PDF 288kB 12/27/2021
Testopel PDF 318kB 03/25/2022
Testosterone Therapy PDF 318kB 03/25/2022
Tezspire PDF 300kB 06/13/2022
Tivdak PDF 277kB 11/22/2021
Trelstar PDF 276kB 12/27/2021
Trikafta PDF 63kB 11/20/2020
Trisenox PDF 56kB 11/26/2019
Trodelvy PDF 62kB 06/10/2021
Trogarzo PDF 279kB 12/27/2021
Tymlos PDF 61kB 11/20/2020
Tysabri PDF 291kB 02/09/2022
U
Ultomiris PDF 284kB 12/27/2021
Unituxin PDF 60kB 08/14/2020
Uplizna PDF 287kB 12/27/2021
V
Vectibix PDF 55kB 11/26/2019
Velcade PDF 63kB 05/14/2021
Vimizim PDF 279kB 12/27/2021
Vincasar PFS PDF 65kB 08/14/2020
Vitrakvi PDF 53kB 08/26/2019
Vyepti PDF 289kB 12/27/2021
Vyndamax, Vyndaqel PDF 63kB 08/14/2020
Vyvgart PDF 299kB 06/22/2022
Vyxeos PDF 59kB 08/14/2020
X
Xgeva PDF 306kB 02/09/2022
Xiaflex PDF 258kB 06/22/2022
Xipere PDF 289kB 03/21/2022
Xofigo PDF 60kB 08/14/2020
Xolair PDF 292kB 12/27/2021
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 280kB 03/25/2022
Zoladex PDF 268kB 03/21/2022
Zulresso PDF 60kB 08/14/2020
Zynlonta PDF 51kB 06/10/2021