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Services
Services
Assistance
Children
Disabilities & Aging
Other Services
Find a Document
Find a Document
For Providers
Publications
The Impact
Forms
About
About
DHS Online Services
Data Dashboards
DHS Leadership
Fraud and Abuse
Contact Us
Contact Us
DHS Press Office
Helpful Phone Numbers
DHS Offices
Feedback Form
For Providers
For Providers
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Department of Human Services
>
For Providers
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Pharmacy Services
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Pharmacy Services Fax Forms
Begin Main Content Area
Page Content
Fee-For-Service Pharmacy Services
Prior Authorization Fax Forms
Related links
Prior Authorization Clinical Guidelines
Prior Authorization General Requirements
Statewide Preferred Drug List (PDL)
Statewide PDL Drugs/Drug Classes Fax Forms
Fee-for-Service Non-PDL Drugs/Drug Classes Fax Forms
Acne Agents, Topical Form
Actemra Form
Aliskiren Agents Form
Alzheimer's Agents Form
Ampyra Form
Analgesics, Non-Opioid Barbiturate Combinations Form
Analgesics, Opioids Long-Acting Form
Analgesics, Opioids Short-Acting Form
Androgenic Agents Form
Angiotensin Modulators Form
Angiotensin Modulator Combinations Form
Antibiotics, Inhaled Form
Anticonvulsants Form
Antidepressants, Other Form
Antidepressants, SSRIs Form
Antiemetics-Antivertigo Agents Form
Antifungals, Oral Form
Antifungals, Topical Form
Antihistamines, Minimally Sedating Form
Antihypertensives, Sympatholytics Form
Antihyperuricemics Form
Antimigraine Agents, Triptans Form
Antimigraine Agents, Other Form
Antimigraine Agents, Other – CGRP Inhibitors
Antiparkinson's Agents Form
Antipsoriatics, Oral Form
Antipsoriatics, Topical Form
Antipsychotics Form
Antivirals, Oral Form
Antivirals, Topical Form
Anxiolytics Form
Arcalyst Form
Aubagio Form
Austedo Form
Beta Blockers Form
Bile Salts Form
Bladder Relaxants Form
Bone Resorption Suppression Agents Form
Botulinum Toxins Form
BPH Agents Form
Bronchodilators, Beta Agonist Form
Calcium Channel Blockers Form
Cesamet Form
Cholbam Form
Cimzia Form
Cinqair Form
Colony Stimulating Factors Form
COPD Agents Form
Cosentyx Form
Daliresp Form
Diabetic Meters and Strips Form
Dupixent Form
Eliquis Form
Enbrel Form
Entresto Form
Entyvio Form
Epinephrine, Self-Injected Form
Erythropoiesis Stimulating Agents Form
Evista Form
Fasenra Form
Fluoroquinolones, Oral Form
Forteo and Tymlos Form
GI Motility, Constipation Form
GI Motility, Diarrhea Form
Gilenya Form
Hepatitis B Agents Form
Hepatitis C Agents Form
Hereditary Angioedema Agents Form
Histamine II Receptor Blockers Form
HIV/AIDS Form
Humira Form
Hypoglycemics, Alpha-Glucosidase Inhibitors Form
Hypoglycemics, Incretin Enhancer Form
Hypoglycemics, Incretin Mimetics Form
Hypoglycemics, Insulin Form
Hypoglycemics, Meglitinides Form
Hypoglycemics, Metformins Form
Hypoglycemics, TZDs Form
Hypoglycemics, SGLT2 Form
Hypoglycemics, Sulfonylureas Form
Ilaris Form
Ilumya Form
Immunomodulators, Atopic Dermatitis Form
Immunomodulators, Topical Form
Ingrezza Form
Inhaled Glucocorticoids Form
Injectable Anticoagulants Form
Injectable Bone Resorption Suppression Agents Form
Intra-Articular Hyaluronates Form
Intranasal Rhinitis Agents Form
Iron, Parenteral Form
Juxtapid and Kynamro Form
Ketorolac Form
Kevzara Form
Kineret Form
Lemtrada Form
Leukotriene Modifiers Form
Lipotropics, Other Form
Macular Degeneration Agents Form
Makena Form
Methotrexate Agents Form
Multiple Sclerosis Form
Neuropathic Pain Form
NSAIDs Form
Nucala Form
Ocaliva Form
Ocrevus Form
Olumiant Form
Oncology Agents, Breast Cancer
Ophthalmic Antibiotics Form
Ophthalmic Immunomodulators Form
Ophthalmics for Allergic Conjunctivitis Form
Ophthalmics, Glaucoma Agents Form
Opiate Dependence Treatments (ORAL) Form
Oral Contraceptives Form
Oral Glucocorticoids Form
Oral Immunosuppressives Form
Oral Oncology Form
Orencia Form
Otezla Form
PAH Agents Form
Pancreatic Enzymes Form
PCSK9 Inhibitors Form
Phosphate Binders Form
Pituitary Suppressive Agents, LHRH Form
Platelet Aggregation Inhibitors Form
Pradaxa Form
Prenatal Vitamins Form
Probuphine Form
Progestational Agents Form
Proton Pump Inhibitor Form
Provigil/Nuvigil Form
Remicade and Biosimilars Form
Savaysa Form
Sedative Hypnotics Form
Siliq Form
Simponi Form
Skeletal Muscle Relaxant Form
Smoking Cessation Form
Soliris Form
Statins Form
Stelara Form
Stimulants and Related Agents Form
Sublocade
Symlin Form
Taltz Form
Tecfidera Form
Tetracyclines Form
Thalidomide and Derivatives Form
Thyroid Hormones Form
Topical Steroids Form
Tremfya Form
Tysabri Form
Ulcerative Colitis Agents Form
Ultomiris Form
Vasodilators, Coronary Form
Xarelto Form
Xeljanz Form
Xenazine Form
Xifaxan Form
Xolair Form
Zinplava Form
Alpha-1 Proteinase Inhibitors Fo
r
m
Brand Medically Necessary Form
Brineura Form
Compounded Prescriptions Form
Corlanor Form
Exondys 51 Form
H.P. Acthar Gel Form
Immune Globulins Form
Kalydeco Form
Korlym Form
Mozobil Form
Multiple Benzodiazepine Prescriptions Form
Nplate Form
Nuedexta Form
Orkambi Form
Promacta Form
Provenge Form
Quantity Limits/Daily Dose Limits Form
Ranexa Form
Radicava Form
Rilutek Form
Santyl Form
Spinraza Form
Symdeko Form
Synagis Form
Therapeutic Duplication Form
Vecamyl Form
Xermelo Form
Xofigo Form