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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. Alzheimer's Agents Form Analgesics, Non-Opioid Barbiturate Combinations Form Analgesics, Opioids Long-Acting Form Analgesics, Opioids Short-Acting Form Androgenic Agents Form Antianginal Agents - Ranexa Form Antibiotics, GI and Related - Xifaxan Form Antibiotics, GI and Related - Zinplava Form Antidepressants, Other Form Antihemophilia Agents Form Antihyperuricemics - Colchicine Form Antihyperuricemics - Krystexxa Form Antimigraine Agents, Other - Acute Treatments Form Antimigraine Agents, Other – CGRP Inhibitors Form Antipsychotics Form Antivirals, CMV - Prevymis Form Bile Salts - Cholbam Form Bile Salts - Ocaliva Form Blood Glucose Meters and Test Strips Form Bone Density Regulators Bone Density Regulators - Evista Form Bone Density Regulators - Forteo and Tymlos Form Botulinum Toxins Form Colony Stimulating Factors Form Cytokine and CAM Antagonists Form Dupixent Form Enzyme Replacements, Gaucher Disease Form Erythropoiesis Stimulating Proteins Form GI Motility, Chronic - Constipation Form GI Motility, Chronic - Diarrhea Form Hepatitis C Agents Form Hereditary Angioedema Agents Form Hypoglycemics, Incretin Enhancers Form Hypoglycemics, Incretin Mimetics Hypoglycemics, Incretin Mimetics - Symlin Form Hypoglycemics, Insulins - Soliqua and Xultophy Form Hypoglycemics, SGLT2 Inhibitors Hypoglycemics, TZDs Intra-Articular Hyaluronates Form Iron Chelating Agents Form Lipotropics, Other - Juxtapid Form Lipotropics, Other - PCSK9 Inhibitors Form Macular Degeneration Agents Form Monoclonal Antibodies - Anti-IL, Anti-IgE Form Multiple Sclerosis Form Oncology Agents, Oral Form Opioid Dependence Treatments (ORAL) Form Opioid Dependence Treatments - Probuphine Form Opioid Dependence Treatments - Sublocade Form Pituitary Suppressive Agents, LHRH Form Platelet Aggregation Inhibitors - Zontivity Form Potassium Removing Agents Form Progestational Agents - Makena Form Proton Pump Inhibitors < 6 Years of Age Form Pulmonary Arterial Hypertension, Oral and Inhaled Form Stimulants and Related Agents Form Stimulants and Related Agents - Provigil/Nuvigil Form Thalidomide and Derivatives Form Thrombopoietics Form Tysabri Form Urea Cycle Disorder Agents Form VMAT2 Inhibitors - Austedo Form VMAT2 Inhibitors - Ingrezza Form VMAT2 Inhibitors - Xenazine Form	Alpha-1 Proteinase Inhibitors Form Brand Medically Necessary Form Brineura Form Compounded Prescriptions Form Corlanor Form Exondys 51 Form H.P. Acthar Gel Form Immune Globulins Form Kalydeco Form Ketorolac Form Korlym Form Mozobil Form Multiple Benzodiazepine Prescriptions Form Nuedexta Form Orkambi Form Provenge Form Quantity Limits/Daily Dose Limits Form Radicava Form Rilutek Form Santyl Form Soliris Form Spinraza Form Symdeko Form Synagis Form Therapeutic Duplication Form Ultomiris Form Vecamyl Form Xermelo Form Xofigo 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.

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Fee-for-Service Pharmacy
Prior Authorization Fax Forms

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Government that Works

Fee-for-Service Pharmacy Prior Authorization Fax Forms

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Governor's Goals

Government that Works

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Schools that Teach

Government that Works

Fee-for-Service Pharmacy
Prior Authorization Fax Forms