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Fee-for-Service Pharmacy
Prior Authorization Fax Forms

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Statewide PDL Drugs/Drug Classes Fax Forms*	Fee-for-Service Non-PDL Drugs/Drug Classes Fax Forms
NOTE: Please use the Non-Preferred Medication Form* for drugs included on the Statewide PDL that do not have a corresponding drug-specific or PDL class-specific form in the list below. Acne Agents, Oral Form Acne Agents, Topical Form Analgesics, Non-Opioid Barbiturate Combinations Form Analgesics, Opioids Long-Acting Form Analgesics, Opioids Short-Acting Form Androgenic Agents Form Antibiotics, GI and Related - Dificid Form Antibiotics, GI and Related - Xifaxan Form Antibiotics, GI and Related - Zinplava Form Antidepressants, Other Form Antifibrotic Respiratory Agents Antihemophilia Agents Form Antihyperuricemics - Krystexxa Form Antipsychotics Form Antivirals, CMV - Livtencity and Prevymis Form Benzodiazepines Form Bile Salts - Cholbam and Ocaliva Form Blood Glucose Meters and Test Strips Form Bone Density Regulators Bone Density Regulators - Evista Form Bone Density Regulators - Evenity, Forteo, Teriparatide, and Tymlos Form Botulinum Toxins Form Colony Stimulating Factors Form Cytokine and CAM Antagonists Form Dupixent Form Enzyme Replacements, Gaucher Disease Form Erythropoiesis Stimulating Agents Form Estrogens Form GI Motility, Chronic Growth Hormones Form Hepatitis C Agents Form Hereditary Angioedema Agents Form Immunomodulators, Atopic Dermatitis Immunosuppressives, Oral - Lupkynis Form Intra-Articular Hyaluronates Form Iron Chelating Agents Form Lipotropics, Other Form Macular Degeneration Agents Form Migraine Acute Treatment Agents Form Migraine Prevention Agents Form Monoclonal Antibodies - Anti-IL, Anti-IgE, Anti-TSLP Form Multiple Sclerosis Form NSAIDs - Ketorolac Form Obesity Treatment Agents Form Oncology Agents, Oral Form Opioid Use Disorder Treatments Form Pituitary Suppressive Agents, LHRH Form Potassium Removing Agents Form Proton Pump Inhibitors < 6 Years of Age Form Pulmonary Hypertension Agents, Oral and Inhaled Form Sickle Cell Anemia Agents Form Stimulants and Related Agents Form Stimulants and Related Agents - Provigil, Nuvigil, Sunosi, and Wakix Form Thalidomide and Derivatives Form Thrombopoietics Form Tysabri Form Urea Cycle Disorder Agents Form VMAT2 Inhibitors Form Zeposia Form	Abecma Form Adstiladrin Form Alpha-1 Proteinase Inhibitors Form (Aralast-NP, Glassia, Prolastin-C, Zemaira) Amvuttra Form Amyloid-Targeted Monoclonal Antibodies (MABs) Form (Aduhelm, Leqembi) Benlysta Form Brand Medically Necessary Form Breyanzi Form Brineura Form Camzyos Form Carvykti Form CFTR Modulators Form (Kalydeco, Orkambi, Symdeko, Trikafta) Complement Inhibitors Form (Empaveli, Enjaymo, Soliris, Tavneos, Ultomiris) Compounded Prescriptions Form Corlanor Form Corticotropin Form Cough and Cold Medications Form Crysvita Form Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides Form (Amondys-45, Exondys 51, Viltepso, Vyondys 53) Elevidys Form Elitek Form Evrysdi Form Filspari Form Imcivree Form Immune Globulins Form Joenja Form Kanuma Form Korlym Form Kuvan Form Kymriah Form Mozobil Form Nuedexta Form Omisirge Form Onpattro Form Palforzia Form Palynziq Form Provenge Form Quantity Limits/Daily Dose Limits Form Radicava Form Roctavian Form Skyclarys Form Skysona Form Spinraza Form Synagis Form Tecartus Form Tegsedi Form Tepezza Form Therapeutic Duplication Form Tzield Form Vecamyl Form Vuity Form Vyjuvek Form Vyndamax Form Vyndaqel Form Xermelo Form Xofigo Form Xyrem and Xywav Form Yescarta Form Zolgensma Form Zynteglo Form

Statewide PDL Drugs/Drug Classes Fax Forms*

Fee-for-Service Non-PDL Drugs/Drug Classes Fax Forms

*NOTE: Please use the Non-Preferred Medication Form for drugs included on the Statewide PDL that do not have a corresponding drug-specific or PDL class-specific form in the list below.

Fee-for-Service Pharmacy Prior Authorization Fax Forms

Related links

Fee-for-Service Pharmacy
Prior Authorization Fax Forms