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 | 304kB | 12/15/2023 | |
| Actemra, Tyenne | 349kB | 01/14/2026 | |
| Acthar Gel Vial | 274kB | 07/18/2025 | |
| Actimmune | 64kB | 05/11/2020 | |
| Adakveo | 285kB | 07/26/2024 | |
| Adcetris | 326kB | 06/20/2025 | |
| Adrucil | 290kB | 12/15/2023 | |
| Adstiladrin | 719kB | 10/10/2023 | |
| Adzynma | 279kB | 05/07/2024 | |
| Akynzeo | 294kB | 12/15/2023 | |
| Aldurazyme | 288kB | 07/26/2024 | |
| Aliqopa | 58kB | 08/14/2020 | |
| Aloxi | 288kB | 12/26/2023 | |
| Alimta | 302kB | 06/20/2025 | |
| Alymsys, Avastin | 334kB | 07/18/2025 | |
| Amondys 45, Exondys 51, Vyondys 53 | 292kB | 11/21/2025 | |
| Ampyra | 61kB | 11/20/2020 | |
| Amvuttra | 326kB | 06/20/2025 | |
| Anktiva | 268kB | 07/18/2025 | |
| Aphexda | 278kB | 01/14/2026 | |
| Apretude | 294kB | 07/26/2024 | |
| Aralast NP, Glassia, Prolastin C, Zemaira | 301kB | 10/13/2025 | |
| Aranesp | 283kB | 10/01/2024 | |
| Arcalyst | 65kB | 07/14/2021 | |
| Arranon | 58kB | 08/26/2019 | |
| Asparlas | 58kB | 08/14/2020 | |
| Aveed | 286kB | 01/14/2026 | |
| Avsola, Inflectra, Remicade, Renflexis | 345kB | 01/14/2026 | |
| Axtle | 277kB | 06/20/2025 | |
| AZMIRO | 279kB | 01/14/2026 | |
| B | |||
| BAL in Oil, Edetate Calcium Disodium | 278kB | 12/26/2023 | |
| Bavencio | 258kB | 04/21/2022 | |
| Beleodaq | 60kB | 08/14/2020 | |
| Belrapzo, Bendeka, Treanda | 307kB | 04/11/2025 | |
| Benlysta | 298kB | 08/23/2024 | |
| Beovu, Byooviz, Cimerli, Lucentis, Vabysmo | 280kB | 10/13/2025 | |
| Berinert, Cinryze | 306kB | 01/14/2026 | |
| Besponsa | 263kB | 07/26/2024 | |
| Beqvez | 261kB | 04/11/2025 | |
| Bizengri | 278kB | 02/28/2025 | |
| Bkemv, Epysqli, Soliris | 294kB | 10/13/2025 | |
| Blenrep | 270kB | 11/15/2022 | |
| Bleomycin | 283kB | 12/26/2023 | |
| Blincyto | 274kB | 01/14/2026 | |
| Bomyntra, Osenvelt, Wyost, Xgeva | 291kB | 01/14/2026 | |
| Boruzu | 267kB | 06/20/2025 | |
| Botox | 311kB | 07/18/2025 | |
| Braftovi | 61kB | 11/20/2020 | |
| Brineura | 279kB | 07/18/2025 | |
| Briumvi | 292kB | 11/21/2025 | |
| Bethkis, Cayston, Kitabis Pak, TOBI, TOBI Podhaler | 92kB | 11/20/2020 | |
| C | |||
| Cabenuva | 326kB | 05/09/2025 | |
| Cablivi | 294kB | 06/20/2025 | |
| Camcevi, Eligard, Vabrinty | 263kB | 01/14/2026 | |
| Carboplatin | 288kB | 12/26/2023 | |
| Casgevy (SSD) | 292kB | 07/18/2025 | |
| Casgevy (TDB) | 301kB | 07/18/2025 | |
| Ceprotin | 289kB | 05/09/2023 | |
| Cerezyme, Elelyso, VPRIV | 285kB | 10/01/2024 | |
| CGRP Inhibitors | 67kB | 09/13/2021 | |
| Cholbam | 63kB | 05/11/2020 | |
| Cimzia | 406kB | 01/14/2026 | |
| Cinqair | 303kB | 07/18/2025 | |
| Cisplatin | 289kB | 12/26/2023 | |
| Clotting Factors | 313kB | 01/14/2026 | |
| Columvi | 266kB | 04/11/2025 | |
| Compound Medication | 290kB | 07/18/2025 | |
| Conexxence, Jubbonti, Prolia, Stoboclo | 281kB | 01/14/2026 | |
| Copaxone | 265kB | 11/21/2025 | |
| Cortrophin Gel | 272kB | 05/09/2025 | |
| Cosela | 281kB | 01/20/2025 | |
| Cosentyx (Intravenous) | 294kB | 01/14/2026 | |
| Crysvita | 292kB | 01/14/2026 | |
| Cyramza | 266kB | 12/26/2023 | |
| Cytarabine | 287kB | 12/26/2023 | |
| D | |||
| Dacarbazine | 275kB | 12/26/2023 | |
| Danyelza | 300kB | 11/15/2022 | |
| Darzalex | 316kB | 10/21/2024 | |
| Datroway | 285kB | 11/21/2025 | |
| Daunorubicin | 55kB | 11/26/2019 | |
| Daxxify | 263kB | 01/14/2026 | |
| Docivyx | 296kB | 01/14/2026 | |
| Duopa | 295kB | 12/26/2023 | |
| Durysta | 289kB | 05/22/2024 | |
| Dysport, Xeomin | 268kB | 01/14/2026 | |
| E | |||
| Egrifta | 61kB | 02/05/2020 | |
| Elahere | 261kB | 12/26/2023 | |
| Elaprase | 312kB | 12/26/2023 | |
| Elfabrio | 274kB | 08/23/2024 | |
| Elrexfio | 379kB | 12/15/2023 | |
| Emend, Cinvanti | 292kB | 12/26/2023 | |
| Empliciti, Ninlaro | 277kB | 12/26/2023 | |
| ENCELTO | 166kB | 01/14/2026 | |
| Enhertu | 311kB | 04/11/2025 | |
| Enjaymo | 295kB | 05/09/2025 | |
| Enspryng | 68kB | 11/20/2020 | |
| Entyvio Pen | 289kB | 09/09/2025 | |
| Entyvio Vial | 305kB | 11/21/2025 | |
| Epidiolex | 63kB | 11/20/2020 | |
| Epkinly | 286kB | 09/09/2024 | |
| Epogen, Procrit, Retacrit | 287kB | 10/01/2024 | |
| Erbitux | 303kB | 12/26/2023 | |
| Erleada, Nubeqa | 58kB | 08/14/2020 | |
| Erwinase | 269kB | 11/15/2022 | |
| Etopophos, Toposar | 283kB | 07/26/2024 | |
| Evenity | 285kB | 12/26/2023 | |
| Evkeeza | 297kB | 01/14/2026 | |
| Evomela | 270kB | 11/15/2022 | |
| Evrysdi | 84kB | 11/20/2020 | |
| Eylea, Eylea HD, Pavblu | 255kB | 10/13/2025 | |
| F | |||
| Fabrazyme | 289kB | 08/23/2024 | |
| Fasenra | 306kB | 07/18/2025 | |
| Faslodex | 277kB | 12/26/2023 | |
| Feraheme | 276kB | 10/13/2025 | |
| Fertility | 294kB | 01/14/2026 | |
| Fibryga, RiaSTAP | 279kB | 01/14/2026 | |
| Flolan, epoprostenol, Veletri | 294kB | 01/14/2026 | |
| Floxuridine | 272kB | 12/26/2023 | |
| Focinvez | 260kB | 10/21/2024 | |
| Fusilev | 275kB | 04/11/2025 | |
| G | |||
| Gamifant | 283kB | 10/13/2025 | |
| Gattex | 60kB | 08/14/2020 | |
| Gazyva | 281kB | 12/26/2023 | |
| Gemzar | 281kB | 12/26/2023 | |
| General Injectables | 285kB | 07/18/2025 | |
| General Medication Prior Authorization | 272kB | 07/18/2025 | |
| Givlaari | 288kB | 01/14/2026 | |
| Glucose Monitoring Supplies | 265kB | 01/14/2026 | |
| Grafapex | 266kB | 06/20/2025 | |
| Granix, Neupogen, Nypozi, Releuko | 277kB | 06/20/2025 | |
| Growth Hormones (Genotropin, Humatrope, Norditropin Flexpro, Nutropin AQ, Omnitrope, Saizen, Zomacton) | 328kB | 10/13/2025 | |
| Growth Hormone (Serostim) | 327kB | 10/13/2025 | |
| H | |||
| Halaven | 261kB | 12/26/2023 | |
| Hemgenix | 306kB | 04/11/2025 | |
| Hemlibra | 57kB | 11/26/2019 | |
| Hepatitis | 294kB | 02/09/2022 | |
| Hepzato | 263kB | 06/20/2025 | |
| Herceptin, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera | 312kB | 07/18/2025 | |
| Herceptin Hylecta | 283kB | 04/11/2025 | |
| Hyaluronic Acid Drugs | 319kB | 01/10/2024 | |
| Hycamtin IV | 281kB | 12/26/2023 | |
| I | |||
| Idiopathic Pulmonary Fibrosis Therapy | 62kB | 08/14/2020 | |
| iDose TR Implant | 281kB | 05/22/2024 | |
| Ilaris | 340kB | 07/18/2025 | |
| Ilumya | 293kB | 01/14/2026 | |
| Iluvien | 308kB | 07/18/2025 | |
| Imaavy | 287kB | 11/21/2025 | |
| Imdelltra | 310kB | 11/21/2025 | |
| Imfinzi | 298kB | 07/18/2025 | |
| Imjudo | 283kB | 10/21/2024 | |
| Imlygic | 261kB | 11/15/2022 | |
| Imuldosa, Otulfi, Pyzchiva, Stelara, Ustekinumab, Steqeyma IV | 272kB | 01/14/2026 | |
| Infugem | 263kB | 09/14/2022 | |
| Injectafer | 278kB | 10/13/2025 | |
| Intravenous Immune Globulin (IVIG) -SCIG | 477kB | 11/21/2025 | |
| Iron Chelating Agents | 65kB | 11/20/2020 | |
| Isuprel | 262kB | 06/20/2025 | |
| IVRA | 261kB | 10/13/2025 | |
| Ixempra | 306kB | 12/26/2023 | |
| Izervay | 287kB | 01/10/2024 | |
| J | |||
| Jelmyto | 277kB | 11/15/2022 | |
| Jemperli | 298kB | 04/11/2025 | |
| Jetrea | 59kB | 08/14/2020 | |
| Jevtana | 259kB | 12/26/2023 | |
| Juxtapid | 135kB | 02/05/2020 | |
| K | |||
| Kadcyla | 288kB | 12/26/2023 | |
| Kalbitor | 288kB | 01/14/2026 | |
| Kalydeco | 86kB | 11/20/2020 | |
| Kanuma | 282kB | 12/26/2023 | |
| Kebilidi | 233kB | 03/19/2025 | |
| Ketalar | 264kB | 06/20/2025 | |
| Keytruda | 348kB | 08/01/2025 | |
| Khapzory | 259kB | 04/11/2025 | |
| Kimmtrak | 255kB | 11/15/2022 | |
| Kineret | 69kB | 08/14/2020 | |
| Korlym | 59kB | 02/05/2020 | |
| Korsuva | 293kB | 01/20/2025 | |
| Krystexxa | 314kB | 08/01/2025 | |
| Kyprolis | 263kB | 04/05/2024 | |
| L | |||
| Lartruvo | 278kB | 12/26/2023 | |
| Lamzede | 343kB | 06/20/2025 | |
| Lemtrada | 288kB | 11/21/2025 | |
| Lenmeldy | 255kB | 07/18/2025 | |
| Leqvio | 232kB | 11/21/2025 | |
| Lupron Depot-PED, Fensolvi, Firmagon, Supprelin LA, Triptodur, Vantas | 314kB | 06/20/2025 | |
| Levorphanol | 67kB | 11/20/2020 | |
| Libtayo | 276kB | 04/05/2024 | |
| Loqtorzi | 285kB | 04/05/2024 | |
| Lumizyme | 280kB | 08/07/2024 | |
| Lumoxiti | 270kB | 11/15/2022 | |
| Lunsumio | 298kB | 04/11/2025 | |
| Luxturna | 285kB | 04/11/2025 | |
| Lyfgenia | 332kB | 07/18/2025 | |
| Lynozyfic | 259kB | 10/13/2025 | |
| M | |||
| Macrilen | 52kB | 08/26/2019 | |
| Makena | 257kB | 03/21/2022 | |
| Margenza | 278kB | 11/15/2022 | |
| Marqibo | 270kB | 11/15/2022 | |
| Mektovi | 57kB | 11/20/2020 | |
| Mepsevii | 280kB | 07/26/2024 | |
| Mircera | 279kB | 10/01/2024 | |
| Monjuvi | 272kB | 11/15/2022 | |
| Monoferric | 276kB | 10/13/2025 | |
| Mozobil | 281kB | 01/14/2026 | |
| Multiple Sclerosis | 310kB | 12/26/2023 | |
| Mvasi, Vegzelma, Zirabev | 337kB | 07/18/2025 | |
| Mylotarg | 60kB | 11/20/2020 | |
| Myobloc | 263kB | 01/14/2026 | |
| N | |||
| Naglazyme | 281kB | 07/26/2024 | |
| Nerlynx | 60kB | 11/20/2020 | |
| Nexviazyme | 288kB | 08/07/2024 | |
| Niktimvo | 264kB | 08/01/2025 | |
| Nipent | 277kB | 12/26/2023 | |
| Non-Specific Gene Therapy | 716kB | 10/10/2023 | |
| Nplate | 300kB | 11/21/2025 | |
| Nucala | 324kB | 08/01/2025 | |
| Nulibry | 285kB | 08/07/2024 | |
| Nulojix | 274kB | 01/14/2026 | |
| O | |||
| Ocrevus | 284kB | 11/21/2025 | |
| Ocrevus Zunovo | 284kB | 01/20/2025 | |
| Omvoh Vial | 293kB | 01/14/2026 | |
| Onivyde | 274kB | 01/14/2026 | |
| Onpattro | 283kB | 02/28/2025 | |
| Opdivo | 331kB | 07/18/2025 | |
| Opdivo Qvantig | 310kB | 07/18/2025 | |
| Opdualag | 283kB | 12/26/2023 | |
| Opioids | 294kB | 01/10/2024 | |
| Oral Fentanyl | 59kB | 08/14/2020 | |
| Orencia (Subcutaneous) | 284kB | 12/26/2023 | |
| Orencia vial (intravenous) | 301kB | 01/14/2026 | |
| Orkambi | 62kB | 11/20/2020 | |
| Otulfi SC, Pyzchiva SC, Stelara SC, Ustekinumab SC (by Janssen) | 286kB | 01/14/2026 | |
| Oxaliplatin | 279kB | 12/26/2023 | |
| Oxervate | 61kb | 11/20/2020 | |
| Oxlumo | 310kB | 02/28/2025 | |
| P | |||
| Paclitaxel | 279kB | 12/26/2023 | |
| Padcev | 275kB | 05/07/2024 | |
| Palonosetron | 292kB | 02/17/2025 | |
| Parsabiv | 283kB | 05/09/2025 | |
| Pedmark | 307kB | 10/13/2025 | |
| Pegfilgrastim | 286kB | 01/14/2026 | |
| Pemetrexed Disodium | 296kB | 12/26/2023 | |
| Pemfexy | 300kB | 06/20/2025 | |
| Pemgarda | 283kB | 02/28/2025 | |
| PEMRYDI RTU | 278kB | 06/07/2024 | |
| Pepaxto | 306kB | 12/26/2023 | |
| Perjeta | 291kB | 12/26/2023 | |
| Phesgo | 279kB | 12/26/2023 | |
| PiaSky | 292kB | 11/21/2025 | |
| Polivy | 271kB | 12/26/2023 | |
| Pombiliti | 306kB | 08/07/2024 | |
| Portrazza | 275kB | 12/26/2023 | |
| Poteligeo | 271kB | 11/15/2022 | |
| Praluent | 93kB | 02/05/2020 | |
| Procysbi | 58kB | 08/14/2020 | |
| Proleukin | 286kB | 05/09/2025 | |
| Promacta | 85kB | 08/19/2021 | |
| Provenge | 272kB | 10/13/2025 | |
| Q | |||
| Qalsody | 328kB | 05/09/2025 | |
| R | |||
| Radicava | 293kB | 07/18/2025 | |
| Reblozyl | 327kB | 05/09/2025 | |
| Rebyota | 265kB | 08/01/2024 | |
| Remodulin | 295kB | 01/14/2026 | |
| Revatio | 263kB | 01/14/2026 | |
| Revcovi | 240kB | 05/09/2023 | |
| Riabni, Rituxan, Ruxience, Truxima | 330kB | 11/21/2025 | |
| Rituxan Hycela | 286kB | 11/21/2025 | |
| Roctavian | 215kB | 11/21/2025 | |
| Rolvedon | 282kB | 01/14/2026 | |
| Ruconest | 285kB | 01/14/2026 | |
| Rybrevant | 283kB | 02/17/2025 | |
| Ryplazim | 304kB | 05/09/2025 | |
| Rylaze | 263kB | 11/15/2022 | |
| Rystiggo | 299kB | 11/21/2025 | |
| Rytelo | 291kB | 10/21/2024 | |
| Ryzneuta | 257kB | 01/14/2026 | |
| S | |||
| Sandostatin, Sandostatin LAR Depot | 319kB | 11/21/2025 | |
| Saphnelo | 326kB | 02/22/2023 | |
| Sarclisa | 274kB | 11/21/2025 | |
| Scenesse | 264kB | 07/26/2024 | |
| Selarsdi IV, Ustekinumab-ttwe IV, Yesintek IV | 269kB | 01/14/2026 | |
| Selarsdi, Yesintek (subcutaneous) 45mg vial | 302kB | 01/14/2026 | |
| Signifor LAR | 353kB | 07/26/2024 | |
| Simponi Aria | 300kB | 01/20/2025 | |
| Skyrizi Vial | 288kB | 09/09/2025 | |
| Skysona | 344kB | 02/17/2025 | |
| Soliris, Bkemv, Epysqli | 300kB | 08/18/2025 | |
| Somatuline Depot | 311kB | 11/21/2025 | |
| Somavert | 286kB | 12/26/2023 | |
| Spevigo | 287kB | 01/20/2025 | |
| Spinraza | 307kB | 09/09/2025 | |
| Spravato | 286kB | 05/09/2025 | |
| Sublingual Allergen Immunotherapy | 64kB | 05/11/2020 | |
| Sunlenca | 255kB | 11/21/2025 | |
| Sunosi, Wakix | 67kB | 05/11/2020 | |
| Sustol | 276kB | 12/26/2023 | |
| Syfovre | 293kB | 05/22/2024 | |
| Sylatron | 77kB | 08/26/2019 | |
| Symdeko | 84kB | 11/20/2020 | |
| Sylvant | 274kB | 12/26/2023 | |
| Synagis | 305kB | 11/21/2025 | |
| T | |||
| Taltz | 71kB | 08/14/2020 | |
| Talvey | 269kB | 12/26/2023 | |
| Taxotere | 276kB | 12/26/2023 | |
| Tecentriq | 300kB | 11/21/2025 | |
| Tecentriq Hybreza | 280kB | 11/21/2025 | |
| Tecvayli | 302kB | 06/07/2024 | |
| Temodar IV | 267kB | 12/26/2023 | |
| Tepezza | 289kB | 05/07/2024 | |
| Tepylute | 287kB | 11/21/2025 | |
| Testopel | 264kB | 01/14/2026 | |
| Tevimbra | 286kB | 02/28/2025 | |
| Tezspire | 282kB | 09/09/2025 | |
| Thrombate III | 282kB | 01/20/2025 | |
| Tivdak | 286kB | 07/18/2025 | |
| Tofidence | 318kB | 01/14/2026 | |
| Trelstar | 277kB | 12/26/2023 | |
| Tremfya IV | 270kB | 11/21/2025 | |
| Trikafta | 63kB | 11/20/2020 | |
| Trisenox | 277kB | 12/26/2023 | |
| Trodelvy | 779kB | 08/11/2023 | |
| Trogarzo | 288kB | 09/09/2024 | |
| Tyenne | 323kB | 07/11/2024 | |
| Tymlos | 61kB | 11/20/2020 | |
| Tyruko, Tysabri | 294kB | 01/14/2026 | |
| Tyvaso | 286kB | 01/14/2026 | |
| Tzield | 290kB | 04/05/2024 | |
| U | |||
| Ultomiris | 292kB | 10/13/2025 | |
| Unituxin | 60kB | 08/14/2020 | |
| Uplizna | 302kB | 11/21/2025 | |
| Uptravi intravenous infusion | 279kB | 01/14/2026 | |
| V | |||
| Vectibix | 275kB | 12/26/2023 | |
| Velcade | 288kB | 06/20/2025 | |
| Veopoz | 276kB | 01/14/2026 | |
| Vidaza | 273kB | 12/26/2023 | |
| Viltepso | 285kB | 11/21/2025 | |
| Vimizim | 281kB | 07/26/2024 | |
| Vincasar PFS | 268kB | 12/26/2023 | |
| Vivimusta | 287kB | 12/26/2023 | |
| Vyepti | 283kB | 07/11/2024 | |
| Vyjuvek | 327kB | 11/21/2025 | |
| Vyloy | 260kB | 02/17/2025 | |
| Vyndamax, Vyndaqel | 63kB | 08/14/2020 | |
| Vyvgart Hytrulo | 297kB | 01/14/2026 | |
| Vyvgart IV | 295kB | 01/14/2026 | |
| Vyxeos | 59kB | 08/14/2020 | |
| X | |||
| Xenpozyme | 285kB | 01/14/2026 | |
| Xiaflex | 268kB | 01/14/2026 | |
| Xipere | 306kB | 06/20/2025 | |
| Xofigo | 60kB | 08/14/2020 | |
| Xolair | 311kB | 11/21/2025 | |
| Xyrem | 62kB | 08/14/2020 | |
| Y | |||
| Yervoy | 282kB | 07/18/2025 | |
| Yondelis | 83kB | 03/22/2021 | |
| Z | |||
| Zaltrap | 269kB | 12/26/2023 | |
| Zepzelca | 269kB | 03/31/2023 | |
| ZEVASKYN | 169kB | 09/09/2025 | |
| Ziihera | 270kB | 07/18/2025 | |
| Zilretta | 255kB | 08/07/2024 | |
| Zoladex | 277kB | 05/22/2024 | |
| Zolgensma | 259kB | 01/20/2025 | |
| Zulresso | 288kB | 10/01/2024 | |
| Zusduri | 283kB | 11/21/2025 | |
| Zymfentra | 299kB | 09/09/2025 | |
| Zynlonta | 276kB | 11/15/2022 | |
| Zynteglo | 345kB | 07/18/2025 | |
| Zynyz | 300kB | 08/18/2025 |