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Phone: 1-888-566-0008 option 4
Email: pharmacym@bmchp.org

PA Forms & Clinical Guidelines

MassHealth

BMC HealthNet Plan members and providers can search the BMC HealthNet Plan Formulary for coverage of specific medications. If the provider feels that it is medically necessary for a member to take a medication belonging to a pharmacy program, he/she may submit a prior authorization request to the Plan by fax or online submission using the appropriate form below. 

  • If the request meets criteria, BMC HealthNet Plan will cover the drug.
  • If the request is denied, the member and the authorized appeal representative have the right to appeal the decision. 

Please review clinical guidelines before submitting prior authorization requests. Be sure to provide complete information on the form. To request a drug that is not listed on the table, please use the general medication request form. Contact us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

Use the forms below to request a prior authorization for a newly marketed drug, a brand-name drug, or for quantity limit exceptions.

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A

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Medical Drug Name Clinical Criteria Prior Authorization Form
Abilify Antipsychotics Antipsychotics PA Form
Abilify DiscMelt Antipsychotics Antipsychotics PA Form
Absorica Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Abstral Opioids Opioids PA Form
Acanya Acne and Rosacea Agents Acne and Rosacea (Topical) PA Form
Accretropin Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Accu-Chek Blood Glucose Test Products Blood Glucose Test Strips PA Form
Aciphex Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Actemra Systemic Immunomodulators Systemic Immunomodulators PA Form
Acthar Gel, H.P. Acthar Gel Acthar Gel H.P. PA Form
Acticlate Antibiotics (systemic) Antibiotics (systemic) PA Form
Actonel Bisphosphonates Bisphosphonates PA Form
Actonel with Calcium Bisphosphonates Bisphosphonates PA Form
Acuvail Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic Anti-Allergy/Anti-Inflammatory PA Form
Acyclovir ointment Anti-Herpes Agents Anti-Herpes Agents PA Form
Aczone Acne and Rosacea Agents Acne and Rosacea (Topical) PA Form
Adapalene Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Adcetris Antineoplastic Agents Antineoplastic Agents PA Form
Adcirca Pulmonary Hypertension Pulmonary Hypertension PA Form
Adempas Pulmonary Hypertension Pulmonary Hypertension PA Form
Advair Diskus Respiratory Medications (Inhaled) Respiratory Medications Inhaled PA Form
Advair HFA Respiratory Medications (Inhaled) Respiratory Medications Inhaled PA Form
Advate rAHF-PFM Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Advicor HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Advocate Blood Glucose Test Products Blood Glucose Test Strips PA Form
Adynovate Blood Clotting Disorders Medications Blood Clotting Disorders Medications PA Form
Almotriptan Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Alocril Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Alomide Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Aloxi Antiemetics Antiemetics PA Form
Alphagan P 0.1% Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Alphanate, Alphanate VWF Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Alphanine SD Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Alprazolam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Alrex Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Alsuma Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Altabax Altabax Altabax PA Form
Altoprev HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Amitiza Amitiza- Linzess Amitiza- Linzess PA Form
Amitriptyline Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Amlodipine/atorvastatin HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Amlodipine-telmisartan Angiotensin Receptor Antagonists Angiotensin Receptor Antagonist PA Form
Amlodipine-Valsartan Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Exforge-Exforge HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Amoxapine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Amphetamine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Ampyra Multiple Sclerosis Multiple Sclerosis PA Form
Amrix Skeletal Muscle Relaxants Skeletal Muscle Relaxants PA Form
Anadrol Anabolic Steroids Anabolic Steroids PA Form
Animi-3 Brand Name Prescription Vitamins Topical Medications PA Form
Anoro Ellipta Respiratory Medications Inhaled Respiratory Medications Inhaled PA Form
Antara (fenofibrate 43, 130 mg) Fibric Acid Derivatives Fibric Acids Derivatives PA Form
Antidepressants < 6 y.o. Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Anzemet Antiemetics Antiemetics PA Form
Apexicon E Topical Corticosteroids Topical Corticosteroids PA Form
Aplenzin Antidepressants Antidepressants PA Form
Aptensio XR ADHD Medications ADHD Medications PA Form

PBHM PA Form
Aptiom Anticonvulsants Anticonvulsants-PA-Form
Aranesp Erythropoiesis Stimulating Agents Erythropoiesis Stimulating Agents PA Form
Arcalyst Systemic Immunomodulators Systemic Immunomodulators PA Form
Aripiprazole Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Asacol HD Inflammatory Bowel Agents Inflammatory Bowel Agents PA Form
Ascensia Blood Glucose Test Products Blood Glucose Test Strips PA Form
Asenapine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Atelvia Bisphosphonates Bisphosphonates PA Form
Atomoxetine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Avita Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Avodart BPH Medications BPH Medications PA Form
Axert Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
AzaSite Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Azelastine Nasal Nasal Antihistamines Nasal Antihistamines PA Form
Azelastine Ophthalmic Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Azopt Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Azor Angiotensin Receptor Antagonists Angiotensin Receptor Antagonist PA Form

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Bactroban 2% Nasal Ointment Topical Medications Topical Medications (Misc) PA Form
Banzel Anticonvulsants Anticonvulsants-PA-Form

PBHMI PA Form
Beconase, Beconase AQ Nasal Corticosteroids Nasal Corticosteroids PA Form
Beleodaq Antineoplastic Agents Antineoplastic Agents PA Form
BeneFIX Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Benicar-Benicar HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonist PA Form
Benlysta Systemic Immunomodulators Systemic Immunomodulators PA Form
Benzamycin Gel Pak Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Benziq Acne and Rosacea Agents Acne and Rosacea (Topical) PA Form
Benzodiazepine < 6 y.o. Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Bepreve Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic Anti-Allergy Anti-Inflammatory PA Form
Berinert Hereditary Angioedema Hereditary Angioedema PA Form
Betoptic-S Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Binosto Bisphosphonates Bisphosphonates PA Form
Bivigam IVIG, SCIG IVIG, SCIG PA Form
Blephamide SOP Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Blincyto Antineoplastic Agents Antineoplastic Agents PA Form
Boniva Bisphosphonates Bisphosphonates PA Form
Bosulif Antineoplastic Agents Antineoplastic Agents PA Form
Botox Botulinum Toxin Botulinum Toxin PA Form
Brevoxyl Kit Complex Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Brilinta Antiplatelet Agents Antiplatelet Agents PA Form
Brimonidine 0.15% Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Brintellix Antidepressants Antidepressants PA Form
Brisdelle Antidepressants Antidepressants PA Form
Bromfenac Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic Anti-Allergy Anti-Inflammatory PA Form
Budesonide Nasal Corticosteroids Nasal Corticosteroids PA Form
Bunavail Buprenorphine Products Buprenorphine Products PA Form
Buprenorphine HCL Buprenorphine Products Buprenorphine Products PA Form
buprenorphine/naloxone tablets Buprenorphine Products Buprenorphine Products PA Form
Bupropion Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Buspirone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Butrans Opioids Opioids PA Form
Bydureon Antidiabetic Agents Antidiabetic Agents PA Form
Byetta Antidiabetic Agents Antidiabetic Agents PA Form
Bystolic Beta Blockers Beta Blockers PA Form

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Cambia NSAIDs-COX2 NSAIDs-COX-2 PA Form
Candesartan-Candesartan HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonist PA Form
Capex Shampoo Topical Corticosteroids Topical Corticosteroids PA Form
Caprelsa Antineoplastic Agents Antineoplastic Agents PA Form
Carbaglu Urea Cycle Disorder Agents Urea Cycle Disorder Agents PA Form
Carbamazepine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Carbidopa/levodopa-ODT Dopamine Agonists/Antiparkinsonian Agents Dopamine Agonists/Antiparkinsonian Agents PA Form
Cardura XL BPH Medications BPH Medications PA Form
Carimune IVIG, SCIG IVIG.SCIG PA Form
Carisprodol 250 mg Skeletal Muscle Relaxants Skeletal Muscle Relaxants PA Form
Celecoxib NSAIDs NSAIDs PA Form
Celontin Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Cenfol Brand Name Prescription Vitamins Brand Name Prescription Vitamins PA Form
Cervarix Vaccines Vaccines PA Form
Cesamet Antiemetics Antiemetics PA Form
Chlordiazepoxide Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Chlordiazepoxide / amitriptyline (benzo) Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Chlorpromazine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Cialis 5 mg BPH Medications BPH Medications PA Form
Ciclopirox Topical Antifungal Agents Antifungal Agents PA Form
Ciloxan Ointment Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Cimzia Systemic Immunomodulators Systemic Immunomodulators PA Form
Cinryze Hereditary Angioedema Hereditary Angioedema PA Form
Citalopram Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Clarinex, Clarinex-D, Clarinex Redi-Tabs Antihistamines Antihistamines PA Form
CleverChek Blood Glucose Test Products Blood Glucose Test Strips PA Form
Clindagel Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Clindamycin Aer Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Clindamycin/benzoyl peroxide Gel 1.2-5% Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Clindareach Kit Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Clobazam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Clobetaplus Kit Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Clobetasol Topical Corticosteroids Topical Corticosteroids PA Form
Cloderm Topical Corticosteroids Topical Corticosteroids PA Form
Clomipramine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Clonazepam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Clonidine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Clonidine hydrochloride ER ADHD Medications ADHD Medications PA Form

PBHMI PA Form
Clorazepate Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Clozapine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Coagadex Blood Clotting Disorders Medications Blood Clotting Disorders Medications PA Form
Colyte-Flavor packs Brand Name Prescription PEG Bowel-Prep Agents Brand Name Prescription PEG Bowel-Prep Agents PA Form
Combigan Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Compounds Prescription Compounds Prescription Compounds PA Form
Concerta ADHD Medications ADHD Medications PA Form
Condylox Gel Topical Immunomodulators Topical Immunomodulators
Contour Blood Glucose Test Products Criteria Blood Glucose Test Strips PA Form
Conzip Tramadol Products Tramadol Products PA Form
Copaxone 40mgmL Multiple Sclerosis Multiple Sclerosis PA Form
Cordran Topical Corticosteroids Topical Corticosteroids PA Form
Coreg CR Beta Blockers Beta Blockers PA Form
Corifact Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Cortisporin Cream Topical Medications Topical Medications (MIsc) PA From
Cosentyx Systemic Immunomodulators Systemic Immunomodulators PA Form
Cresemba Antifungal Agents Antifungal Agents PA Form
Crestor HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Cutivate Lotion Topical Corticosteroids Topical Corticosteroids PA Form
Cuvposa Cuvposa Cuvposa PA Form
Cyclobenzaprine 7.5mg Skeletal Muscle Relaxants Skeletal Muscle Relaxants PA Form
Cycloset Antidiabetic Agents Antidiabetic Agents PA Form
Cyramza Antineoplastic Agents Antineoplastic Agents PA Form
Cytogam IVIG, SCIG IVIG, SCIG PA Form
Cerebral Stimulants < 6 y.o. Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form

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Daklinza Hepatitis C Hepatitis C PA Form
Daliresp Respiratory Medications (Oral) Respiratory Medications Oral PA Form
D-amphetamine, dextroamphetamine sulfate Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Daraprim Daraprim Diraprim PA Form
Daytrana ADHD Medications ADHD Medications PA Form
Delizicol Inflammatory Bowel Agents Inflammatory Bowel Agents PA Form
Denavir cream Anti-Herpes Agents Anti-Herpes Agents PA Form
Derma-Smoothe FS Topical Corticosteroids Topical Corticosteroids PA Form
Desipramine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Desloratadine Antihistamines Antihistamines PA Form
Desonate Topical Corticosteroids Topical Corticosteroids PA Form
Desonide Topical Corticosteroids Topical Corticosteroids PA Form
Desonil + Plus Topical Corticosteroids Topical Corticosteroids PA Form
Desoximetasone Topical Corticosteroids Topical Corticosteroids PA Form
Desvenlafaxine ER Antidepressants Antidepressants PA Form

PBHMI PA Form
Desvenlafaxine furnarate ER Antidepressants Antidepressants PA Form

PBHMI PA Form
Dexilant Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Dexmethylphenidate ER, solution ADHD Medications ADHD Medications PA Form

PBHMI PA Form
Dextroamphetamine-amphetamine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Dialyvite Brand Name Prescription Vitamins Medication PA Request Form
Diazepam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Diclegis Antiemetics Antiemetics PA Form
Diclofenac sodium 3% Topical Immunomodulators Topical Immunomodulators PA Form
Differin Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Dificid Antibiotics (systemic) Antibiotics (systemic) PA Form
Diflorasone Diacetate 0.05% Topical Corticosteroids Topical Corticosteroids PA Form
Dihydroergotamine Spray Migrane-Specific Medications (Triptans) Migrane-Specific Medications (Triptans) PA Form
Dilantin Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Divalproex Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Doryx Antibiotics (systemic) Antibiotics (systemic) PA Form
Doxepin Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Doxycycline hyclate Antibiotics (systemic) Antibiotics (systemic) PA Form
Doxycycline 40mg Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Dronabinol Antiemetics Antiemetics PA Form
Duac CS Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Duet DHA-Duet DHA EC Brand Name Prescription Vitamins Brand Name Prescription Vitamins PA Form
Dulera Respiratory Medications (Inhaled) Respiratory Medications Inhaled PA Form
Duloxetine Antidepressants Antidepressants PA Form

PBHMI PA Form
Durezol Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Dutoprol Beta Blockers Beta Blockers PA Form
Dymista Nasal Corticosteroids Nasal Corticosteroids PA Form
Dysport Botulinum Toxin Botulinum Toxin PA Form

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Edarbi/Edarbyclor Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Edluar Insomnia Agents Insomnia Agents PA Form
Effient Antiplatelet Agents Antiplatelet Agents PA Form
Egrifta Egrifta Egrifta PA-Form
Elepsia XR Anticonvulsants Anticonvulsants PA Form
Elidel Atopic Dermatitis Atopic Dermatitis PA Form
Eligard GnRH Agents GnRH Agents PA Form
Eliquis Anticoagulants (Oral) Anticoagulants (Oral) PA Form
Elite Blood Glucose Test Products Criteria Blood Glucose Test Strips PA Form
Eloctate Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Emadine Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Emend Antiemetics Antiemetics PA Form
Enablex Urinary Antispasmodic Medications Urinary Antispasmodic PA Form
Enbrel Systemic Immunomodulators Systemic Immunomodulators PA Form
Entyvio Systemic Immunomodulators Systemic Immunomodulators PA Form
Epaned Epaned Epaned PA Form
Epiduo-Epiduo Forte Gel Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Epifoam aerosol Foam 1-1% Topical Medications Topical Medications (MIsc) PA From
Epogen Erythropoiesis Stimulating Agents Erythropoiesis Stimulating Agents PA Form
Epoprostenol Pulmonary Hypertension Pulmonary Hypertension PA Form
Eprosartan Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Ertaczo Topical Medications Topical Medications (MIsc) PA From
Erwinaze Antineoplastic Agents Antineoplastic Agents PA Form
Esbriet Idiopathic Pulmonary Fibrosis Agents Idiopathic Pulmonary Fibrosis Agents PA Form
Escitalopram Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Eslicarbazepine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Esomeprazole Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Estazolam (benzo) Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Eszopiclone Insomnia Agents Insomnia Agents PA Form

PBHMI PA Form
Ethosuximide Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Ethotoin Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Euflexxa Viscosupplements Viscosupplements PA Form
Evzio Buprenorphine Products Buprenorphine Products PA Form
Exelderm Topical Medications Topical Medications (MIsc) PA From
Exjade Iron Chelating Agents Iron Chelating Agents PA Form
Ezogabine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form

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Fabior Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Fanapt Antipsychotics Antipsychotics PA Form
Farxiga Antidiabetic Agents Antidiabetic Agents PA Form
Farydak Antineoplastic Agents Antineoplastic Agents PA Form
Fazaclo Antipsychotics Antipsychotics PA Form
Feiba VH, NF Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Felbamate Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Felbatol Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Fenofibric Acid Fibric Acid Derivatives Fibric Acid Derivatives PA Form
Fenoglide Fibric Acid Derivatives Fibric Acid Derivatives PA Form
Fentanyl Buccal Lozenge Opioids Opioids PA Form
Fentora Opioids Opioids PA Form
Ferriprox Iron Chelating Agents Iron Chelating Agents PA Form
Fetzima Antidepressants Antidepressants PA Form
Fexofenadine/pseudoephedrine 12 Hr Antihistamines Antihistamines PA Form
Fexofenadine w/wo Pseudoephedrine Antihistamines Antihistamines PA Form
Fibricor Fibric Acid Derivatives Fibric Acid Derivatives PA Form
Finacea Gel-Finacea AER 15% Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Firazyr Hereditary Angioedema Hereditary Angioedema PA Form
Firmagon GnRH Agents GnRH Agents PA Form
Flebogamma IVIG, SCIG IVIG, SCIG PA Form
Flebogamma DIF IVIG, SCIG IVIG, SCIG PA Form
Flector Patch NSAIDs-COX2 NSAIDs-COX-2 PA Form
Flo-Pred Oral Corticosteroids Oral Corticosteroids PA Form
Flunisolide Nasal Spray Nasal Corticosteroids Nasal Corticosteroids PA Form
Fluocinolone Oil Topical Corticosteroids Topical Corticosteroids PA Form
Fluorabon Dro Brand Name Prescription Vitamins Brand Name Prescription Vitamins PA Form
Fluor-A-Day Chew F Brand Name Prescription Vitamins Brand Name Prescription Vitamins PA Form
Fluoxetine 60 mg Antidepressants Antidepressants PA Form

PBHMI PA Form
Fluoxetine DR Antidepressants Antidepressants PA Form

PBHMI PA Form
Fluphenazine PBHMI PBHMI PA Form
Flurazepam (benzo) PBHMI PBHMI PA Form
Fluvastatin HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Fluvoxamine ER Antidepressants Antidepressants PA Form

PBHMI PA Form
Focalin XR ADHD Medications ADHD Medications PA Form
Forfivo Antidepressants Antidepressants PA Form
Forteo Forteo-Prolia-Xgeva Forteo-Prolia-Xgeva PA Form
Fosamax Plus D Solution Bisphosphonates Bisphosphonates PA Form
Fosamax Solution Bisphosphonates Bisphosphonates PA Form
Fotolyn Antineoplastic Agents Antineoplastic Agents PA Form
Frova Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Fulyzaq Fulyzaq Fulyzaq PA Form
Fycompa Anticonvulsants Anticonvulsants-PA-Form

PBHMI PA Form

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GamaSTAN IVIG, SCIG IVIG, SCIG PA Form
Gammagard IVIG, SCIG IVIG, SCIG PA Form
Gammaplex IVIG, SCIG IVIG, SCIG PA Form
Gammar-P IVIG, SCIG IVIG, SCIG PA Form
Gamunex IVIG, SCIG IVIG, SCIG PA Form
Gardasil, Gardasil 9 Vaccines Vaccines PA Form
Gatifloxacin Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Gattex Gattex Gattex PA Form
Gelnique Urinary Antispasmodic Medications Urinary Antispasmodic PA Form
Gel-One Viscosupplements Viscosupplements PA Form
Genotropin Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Giazo Inflammatory Bowel Agents Inflammatory Bowel Agents PA Form
Gilenya Multiple Sclerosis Multiple Sclerosis PA Form
Glucose Test Strips Blood Glucose Test Products Blood Glucose Test Strips PA Form
Glyxambi Antidiabetic Agents Antidiabetic Agents PA Form
Golytely Brand Name Prescription PEG Bowel-Prep Agents Brand Name Prescription PEG Bowel-Prep Agents PA Form
Gralise Anticonvulsants Anticonvulsants-PA-Form
Granisetron Antiemetics Antiemetics PA Form
Grastek SLIT Medications SLIT Medications PA Form
Guanfacine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Glyxambi Antidiabetic Agents Antidiabetic Agents PA Form

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Halac Topical Corticosteroids Topical Corticosteroids PA Form
Halflytely Bowel Prep Brand Name Prescription PEG Bowel-Prep Agents Brand Name Prescription PEG Bowel-Prep Agents PA Form
Halog (E) Topical Corticosteroids Topical Corticosteroids PA Form
Halonate Topical Corticosteroids Topical Corticosteroids PA Form
Haloperidol Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Harvoni Hepatitis C Hepatitis C PA Form
Helidac Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Helixate FS Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Hemangeol Beta Blockers Beta Blockers PA Form
Hemofil-M Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Hetlioz Insomnia Agents Insomnia Agents PA Form
Hizentra IVIG, SCIG IVIG, SCIG PA Form
Horizant Anticonvulsants Anticonvulsants-PA-Form
Humate P Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Humatrope Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Humira Systemic Immunomodulators Systemic Immunomodulators PA Form
Hyalgan Viscosupplements Viscosupplements PA Form
Hydrocortisone Butyrate Topical Corticosteroids Topical Corticosteroids PA Form
Hydromorphone ER Opioids Opioids PA Form
Hyqvia IVIG, SCIG IVIG, SCIG PA Form
Hysingla ER Opioids Opioids PA Form

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Ibandronate Bisphosphonates Bisphosphonates PA Form
Ibrance Antineoplastic Agents Antineoplastic Agents PA Form
Iclusig Antineoplastic Agents Antineoplastic Agents PA Form
Ilaris Systemic Immunomodulators Systemic Immunomodulators PA Form
Ilevro Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Iloperidone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Imbruvica Antineoplastic Agents Antineoplastic Agents PA Form
Imipramine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Imipramine pamoate Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Imiquimod Topical Immunomodulators Topical Immunomodulators PA Form
Immune Globulin IVIG, SCIG IVIG, SCIG PA Form
Incivek Hepatitis C Hepatitis C PA Form
Increlex Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Infergen Hepatitis C Hepatitis C PA Form
Inlyta Antineoplastic Agents Antineoplastic Agents PA Form
InnoPran XL Beta Blockers Beta Blockers PA Form
Intermezzo Insomnia Agents Insomnia Agents PA Form
Intuniv ADHD Medications ADHD Medications PA Form
Invega Antipsychotics Antipsychotics PA Form
Invokamet Antidiabetic Agents Antidiabetic Agents PA Form
Invokana Antidiabetic Agents Antidiabetic Agents PA Form
Iprivask Iprivask Iprivask PA Form
Irenka Antidepressants Antidepressants PA Form
Isocarboxazid Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Iveegam En IVIG, SCIG IVIG, SCIG PA Form
Ixinity Blood Clotting Disorders Medications Blood Clotting Disorders Medications PA Form

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Jalyn BPH Medications BPH Medications PA Form
Janumet; Janumet XR Antidiabetic Agents Antidiabetic Agents PA Form
Januvia Antidiabetic Agents Antidiabetic Agents PA Form
Jardiance Antidiabetic Agents Antidiabetic Agents PA Form
Jentadueto Antidiabetic Agents Antidiabetic Agents PA Form
Jublia Antifungal Agents Antifungal Agents PA Form
Juvisync Antidiabetic Agents Antidiabetic Agents PA Form
Juxtapid Homozygous FH Homozygous FH PA Form

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Kadcyla Antineoplastic Agents Antineoplastic Agents PA Form
Kalbitor Hereditary Angioedema Hereditary Angioedema PA Form
Kalydeco Kalydeco Kalydeco PA Form
Kazano Antidiabetic Agents Antidiabetic Agents PA Form
Ketorolac ophth Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Keytruda Antineoplastic Agents Antineoplastic Agents PA Form
Khedezla Antidepressants Antidepressants PA Form
Kineret Systemic Immunomodulators Systemic Immunomodulators PA Form
Koate-DVI Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Kogenate FS Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Kombiglyze XR Antidiabetic Agents Antidiabetic Agents PA Form
Korlym Korlym Korlym PA Form
Krystexxa Anti Gout Medications Anti Gout Medications PA Form
Kynamro Homozygous FH Homozygous FH PA Form
Kyprolis Antineoplastic Agents Antineoplastic Agents PA Form

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Lacosamide Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Lamictal XR; ODT Anticonvulsants Anticonvulsants-PA-Form
Lamisil granules Antifungal Agents Antifungal Agents PA Form
Lamisil 1% Spray Topical Medications Topical Medications (MIsc) PA From
Lamotrigine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Lamotrigine XR Anticonvulsants Anticonvulsants-PA-Form

PBHMI PA Form
Lansoprazole capsule; soluTab Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Lastacraft Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Latuda Antipsychotics Antipsychotics PA Form
Lazanda Opioids Opioids PA Form
Lemtrada Multiple Sclerosis Multiple Sclerosis PA Form
Lenvima Antineoplastic Agents Antineoplastic Agents PA Form
Lescol XL HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Letairis Pulmonary Hypertension Pulmonary Hypertension PA Form
Leuprolide GnRH Agents GnRH Agents PA Form
Levalbuterol Levalbuterol Levalbuterol PA Form
Levetiracetam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
levetiracetam ER Anticonvulsants Anticonvulsants-PA-Form

PBHMI PA Form
Levocetirizine Dihydrochloride Antihistamines Medication PA Request Form
Levofloxacin drops Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Levomilnacipran Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Lidocaine 3% Topical Medications Topical Medications (MIsc) PA From
Lidorx 3% Topical Medications Topical Medications (MIsc) PA From
Lindane Topical Medications Topical Medications PA Form
Linezolid (IV, tabs) Antibiotics (systemic) Antibiotics (systemic) PA Form
Linzess Amitiza-Linzess Amitiza- Linzess PA Form
Lipofen Fibric Acid Derivatives Fibric Acid Derivatives PA Form
Liptruzet Cholesterol Absorption Inhibitors Cholesterol Absorption Inhibitors PA Form
Lisdexamfetamine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Lithium Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Livalo HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Locoid Topical Corticosteroids Topical Corticosteroids PA Form
Lorazepam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Lorzone Skeletal Muscle Relaxants Skeletal Muscle Relaxants
Lotemax Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Lovaza Omega Fatty Acids - Omega-3-Acid Ethyl Esters Omega Fatty Acids PA Form
Loxapine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Lumigan Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Lupron, Lupron Depot, Lupron Depot Ped GnRH Agents GnRH Agents PA Form
Lurasidone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Luxiq Topical Corticosteroids Topical Corticosteroids PA Form
Lynparza Antineoplastic Agents Antineoplastic Agents PA Form
Lyrica Anticonvulsants Anticonvulsants-PA-Form

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Makena Makena Makena PA Form
Maprotiline Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Marqibo Antineoplastic Agents Antineoplastic Agents PA Form
Mefenamic acid NSAIDs-COX2 NSAIDs-COX-2 PA Form
Mekinist Antineoplastic Agents Antineoplastic Agents PA Form
Mentax 1% C Topical Medications Topical Medications (MIsc) PA From
Meprobamate Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Metaxolone Skeletal Muscle Relaxants Skeletal Muscle Relaxants
Metformin SR 24 hr Antidiabetic Agents Antidiabetic Agents PA Form
Metformin SR Osmotic Antidiabetic Agents Antidiabetic Agents PA Form
Methamphetamine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Methsuximide Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Methylphenidate Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Metoclopramide ODT Metoclopramide ODT Metoclopramide ODT
Midazolam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Millipred solution Oral Corticosteroids Oral Corticosteroids PA Form
Minocycline ER Antibiotics (systemic) Antibiotics (systemic) PA Form
Minocycline HCL Extended Release Acne and Rosacea (Oral) Acne and Rosacea (Oral) PA Form
Mircera Erythropoiesis Stimulating Agents Erythropoiesis Stimulating Agents PA Form
Mirtazapine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Mirvaso Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Modafinil Modafinil-Nuvigil Modafinil-Nuvigil PA Form
Momexin Topical Corticosteroids Topical Corticosteroids PA Form
Monoclate-P Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Mononine Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Montelukast Packet Respiratory Medications (Oral) Respiratory Medications (Oral) PA Form
Mood Stabilizers < 6 y.o. Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Morphine-ER 24HR Opioids Opioids PA Form
Movantik Relistor-Movantik Relistor-Movantik PA Form
Moviprep Brand Name Prescription PEG Bowel-Prep Agents Brand Name Prescription PEG Bowel-Prep Agents PA Form
Moxeza Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Mozobil Mozobil Mozobil PA Form
Myalept Myalept Myalept PA Form
Myobloc Botulinum Toxin Botulinum Toxin PA Form
Myrbetriq Urinary Antispasmodic Medications Urinary Antispasmodic PA Form
Mysoline Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form

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Naproxen CR NSAIDs NSAIDs PA Form
Nasonex Nasal Corticosteroids Nasal Corticosteroids PA Form
Natroba Susp Topical Medications Topical Medications (MIsc) PA From
Nefazodone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Nesina Antidiabetic Agents Antidiabetic Agents PA Form
Neuac Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Neupogen Biologics with Biosimilar Products Biologics with Biosimilar Products PA Form
Neupro Dopamine Agonists Dopamine Agonists PA Form
Nevanac Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic Anti-Allergy Anti-Inflammatory PA Form
Nexium granules Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Niacin ER/Lovastatin HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Niacin ER-Simvastatin HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Norditropin Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Noritate 1% Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Northera Northera Northera PA Form
Nortriptyline Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Novoeight Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
NovoSeven, NovoSeven RT Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Noxafil Antifungal Agents Antifungal Agents PA Form
Nplate Platelet Stimulating Agents Platelet Stimulating Agents PA Form
Nucala Nucala, Xolair Nucala, Xolair PA Form
Nucort Topical Corticosteroids Topical Corticosteroids PA Form
Nucynta ER Opioids Opioids PA Form
Nucynta IR Opioids Opioids PA Form
Nuedexta Nuedexta Nuedexta PA Form
Nuox Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Nutropin Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Nuvigil Modafinil-Nuvigil Modafinil-Nuvigil PA Form

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Obizur Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Octagam IVIG, SCIG 9.129 IVIG, SCIG PA Form
Ofev Idiopathic Pulmonary Fibrosis Agents Idiopathic Pulmonary Fibrosis Agents PA Form
Olanzapine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Oleptro Antidepressants Antidepressants PA Form
Olopatadine Nasal Antihistamines Nasal Antihistamines PA Form
Olux-E Topical Corticosteroids Topical Corticosteroids PA Form
Olysio Hepatitis C Hepatitis C PA Form
Omeprazole-Bicarbonate Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Omnaris Nasal Corticosteroids Nasal Corticosteroids PA Form
Omnitrope Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
ondansetron Antiemetics Antiemetics PA Form
One a Day Brand Name Prescription Vitamins Medication PA Request Form
One Touch Blood Glucose Test Products Criteria Blood Glucose Test Strips PA Form
Onextron Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Onfi Anticonvulsants Anticonvulsants-PA-Form

PBHMI PA Form
Onglyza Antidiabetic Agents Antidiabetic Agents PA Form
Onmel Antifungal Agents Antifungal Agents PA Form
Opana ER Opioids Opioids PA Form
Opdivo Antineoplastic Agents Antineoplastic Agents PA Form
Opsumit Pulmonary Hypertension Pulmonary Hypertension PA Form
Oracea Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Oralair SLIT Medications SLIT Medications PA Form
Orbivan Cap Brand Name Prescription Vitamins Brand Name Prescription Vitamins PA Form
Orencia Systemic Immunomodulators Systemic Immunomodulators PA Form
Orenitram Pulmonary Hypertension Pulmonary Hypertension PA Form
Orphen CDP Skeletal Muscle Relaxants Skeletal Muscle Relaxants PA Form
Orthovisc Viscosupplements Viscosupplements PA Form
Oseni Antidiabetic Agents Antidiabetic Agents PA Form
Otezla Systemic Immunomodulators Systemic Immunomodulators PA Form
Otrexup Systemic Immunomodulators Systemic Immunomodulators PA Form
Oxandrolone Anabolic Steroids Anabolic Steroids PA Form
Oxazepam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Oxcarbazepine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Oxistat Topical Medications Topical Medications (MIsc) PA From
Oxtellar XR Anticonvulsants Anticonvulsants-PA-Form
Oxycontin Opioids Opioids PA Form
Oxymorphone ER Opioids Opioids PA Form
Oxymorphone-IR Opioids Opioids PA Form
Oxytrol Urinary Antispasmodic Medications Urinary Antispasmodic PA Form

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Paliperidone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Pandel Topical Corticosteroids Topical Corticosteroids PA Form
Paroxetine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Pataday Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Patanol Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Pazeo Opthalmic-Antiallergy-Antiinflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Pediaderm HC Topical Corticosteroids Topical Corticosteroids PA Form
Peganone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Pegasys Hepatitis C Hepatitis C PA Form
PEG-Intron Hepatitis C Hepatitis C PA Form
Pennsaid NSAIDs Nsaids PA form
Pentasa Inflammatory Bowel Agents Inflammatory Bowel Agents PA Form
Perampanel Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Perphenazine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Pexeva Antidepressants Antidepressants PA Form
Phenlzine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Phenytek Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Phenytoin Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Picato Topical Immunomodulators Topical Immunomodulators PA Form
Pimozide Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Plegridy Multiple Sclerosis Multiple Sclerosis PA Form
Polygam S/D IVIG, SCIG IVIG, SCIG PA Form
Pomalyst Antineoplastic Agents Antineoplastic Agents PA Form
Potiga Anticonvulsants Anticonvulsants-PA-Form
Potiga Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Pradaxa Anticoagulants (Oral) Anticoagulants (Oral) PA Form
Praluent PCSK9 Inhibitors PCSK9 Inhibitors PA Form
Pramiprexole ER Dopamine Agonists/Antiparkinsonian Agents Dopamine Agonists PA Form
Prednisolone ODT Oral Corticosteroids Oral Corticosteroids PA Form
Pregabalin Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Prenate Brand Name Prescription Vitamins Medication PA Request Form
Prescription Compounds Prescription Compounds Prescription Compounds PA Form
Prevpac Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Prilosec powder packet Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Primidone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Pristiq Antidepressants Antidepressants PA Form
Privigen IVIG SCIG IVIG SCIG PA Form
Procrit Erythropoiesis Stimulating Agents Erythropoiesis Stimulating Agents PA Form
Procysbi Procysbi Procysbi PA Form
Profilnine SD Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Prolensa Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Prolia Forteo-Prolia-Xgeva Forteo-Prolia-Xgeva PA Form
Promacta Platelet Stimulating Agents Platelet Stimulating Agents PA Form
Protonix granules Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Protriptyline Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Pylera Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form

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Qnasl-Qnasl Childrens Nasal Corticosteroids Nasal Corticosteroids PA Form
Quazepam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Qudexy XR Anticonvulsants Anticonvulsants-PA-Form
Quetiapine IR, XR Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Quillivant XR ADHD Medications ADHD Medications PA Form
Qutenza Qutenza Qutenza PA Form

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Rabeprazole Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Ragwitek SLIT Medications SLIT Medications PA Form
Ranexa Ranexa Ranexa PA Form
Rapaflo BPH Medications BPH Medications PA Form
Rasuvo Systemic Immunomodulators Systemic Immunomodulators PA Form
Ravicti Urea Cycle Disorder Agents Urea Cycle Disorder Agents PA Form
Rayos Oral Corticosteroids Oral Corticosteroids PA Form
Rebetol Hepatitis C Hepatitis C PA Form
Rebif Multiple Sclerosis Multiple Sclerosis PA Form
Reclast Bisphosphonates Bisphosphonates PA Form
Recombinate Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Rectiv Rectiv Rectiv PA Form
Relistor Relistor-Movantik Relistor-Movantik PA Form
Relpax Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Remicade Systemic Immunomodulators Systemic Immunomodulators PA Form
Remodulin Pulmonary Hypertension Pulmonary Hypertension PA Form
Renatabs Mis Iron Brand Name Prescription Vitamins Brand Name Prescription Vitamins PA Form
Repatha PCSK9 Inhibitors PCSK9 Inhibitors PA Form
Rescula Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Restasis Restasis Restasis PA Form
Retin-A Micro Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Revatio Oral Susp Pulmonary Hypertension Pulmonary Hypertension PA Form
Rexulti Antipsychotics Antipsychotics PA Form
Riax Acne and Rosacea Agents Acne and Rosacea (Topical) PA Form
Ribapak Hepatitis C Hepatitis C PA Form
Ribasphere Hepatitis C Hepatitis C PA Form
Risedronate 150mg Bisphosphonates Bisphosphonates PA Form
Risperidone ODT Antipsychotics Antipsychotics PA Form
Rituxan Systemic Immunomodulators Systemic Immunomodulators PA Form
Rixubis Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Ropinirole ER Dopamine Agonists/Antiparkinsonian Agents Dopamine Agonists/Antiparkinsonian Agents PA Form
Rosula Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Ruconest Hereditary Angioedema Hereditary Angioedema PA Form
Rufinamide Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Rybix-ODT Tramadol Products Medication PA Request Form
Rytary Dopamine Agonists/Antiparkinsonian Agents Dopamine Agonists/Antiparkinsonian Agents PA Form

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Sabril Anticonvulsants Anticonvulsants-PA-Form
Saizen Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Samsca Samsca Samsca PA Form
Sancuso Antiemetics Antiemetics PA Form
Saphris Antipsychotics Antipsychotics PA Form
Sarafem Antidepressants Antidepressants PA Form
Savaysa Anticoagulants (Oral) Anticoagulants (Oral) PA Form
Savella Savella Savella PA Form
Selegiline Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Selrx Topical Medications Topical Medications (Misc) PA Form
Seroquel XR Antipsychotics Antipsychotics PA Form
Serostim Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Sertraline Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Signifor Signifor Signifor PA Form
Sildenafil Pulmonary Hypertension Pulmonary Hypertension PA Form
Silenor Insomnia Agents Insomnia Agents PA Form
Simbrinza Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Simcor HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Simponi Systemic Immunomodulators Systemic Immunomodulators PA Form
Simponi Aria Systemic Immunomodulators Systemic Immunomodulators PA Form
Sitavig buccal tablet Anti-Herpes Agents Anti-Herpes Agents PA Form
Sivextro Antibiotics (systemic) Antibiotics (systemic) PA Form
Sklice 0.5% Topical Medications Topical Medications (Misc) PA Form
Solodyn Antibiotics (Systemic) Acne and Rosacea (Oral) PA Form
Soolantra Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Sorilux Topical Medications Topical Medications (Misc) PA Form
Sotylize Beta Blockers Beta Blockers PA Form
Sovaldi Hepatitis C Hepatitis C PA Form
Spinosad Susp Topical Medications Topical Medications PA From
Sporanox Antifungal Agents Antifungal Agents PA Form
Sprix NSAIDs-COX2 NSAIDs-COX-2 PA Form
Stavelo Dopamine Agonists/Antiparkinsonian Agents Dopamine Agonists/Antiparkinsonian Agents PA Form
Stavzor Anticonvulsants Anticonvulsants PA Form
Stelara Systemic Immunomodulators Systemic Immunomodulators PA Form
Stiolto Respiratory Medications (Inhaled) Respiratory Medications Inhaled PA Form
Stivarga Antineoplastic Agents Antineoplastic Agents PA Form
Strattera ADHD Medications ADHD Medications PA Form
Suboxone Film Buprenorphine Products Buprenorphine Products PA Form
Subsys Opioids Opioids PA Form
Sumatriptan Nasal Spray Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Sumavel DosePro Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Supartz Viscosupplements Viscosupplements PA Form
Supprelin LA GnRH Agents GnRH Agents PA Form
Sylvant Antineoplastic Agents Antineoplastic Agents PA Form
Symbicort Respiratory Medications (Inhaled) Respiratory Medications Inhaled PA Form
Synagis Synagis Synagis PA Form
Synjardi Antidiabetic Agents Antidiabetic Agents PA Form
Stivarga Antineoplastic Agents Antineoplastic Agents PA Form
Synvisc Viscosupplements Viscosupplements PA Form
Synvisc-One Viscosupplements Viscosupplements PA Form

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Taclonex Sus Topical Medications Topical Medications (Misc) PA Form
Tacrolimus Topical Immunomodulators Topical Immunomodulators PA Form
Tafinlar Antineoplastic Agents Antineoplastic Agents PA Form
Tanzeum Antidiabetic Agents Antidiabetic Agents PA Form
Tazorac Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Tecfidera Multiple Sclerosis Multiple Sclerosis PA Form
Technivie Hepatitis C Hepatitis C PA Form
Telmisartan-Telmisartan HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Temazepam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Temovate Topical Corticosteroids Topical Corticosteroids PA Form
Teveten HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Tev-Tropin Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Texacort Topical Corticosteroids Topical Corticosteroids PA Form
Thioridazine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Tiagabine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Tizanidine Skeletal Muscle Relaxants Skeletal Muscle Relaxants
Tobradex ST Ophthalmic Antibiotics Ophthalmic Antibiotics
Tobrex Ointment Ophthalmic Antibiotics Ophthalmic Antibiotics
Topicort Topical Corticosteroids Topical Corticosteroids PA Form
Topiramate Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Topiramate ER Anticonvulsants Anticonvulsants-PA-Form

PBHMI PA Form
Toviaz Urinary Antispasmodic Medications Urinary Antispasmodic PA Form
Tracleer Pulmonary Hypertension Pulmonary Hypertension PA Form
Tradjenta Antidiabetic Agents Antidiabetic Agents PA Form
Tramadol Extended-release Tramadol Products Tramadol Products PA Form
Tranexamic Acid Tranexamic Acid Tranexamic Acid PA Form
Tranylcypromine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Travoprost Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Trazodone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Treanda Antineoplastic Agents Antineoplastic Agents PA Form
Trelstar Depot, LA GnRH Agents GnRH Agents PA Form
Tretinoin-Tretinoin Gel 0.05% Acne and Rosacea Agents Acne and Rosacea (Topical) PA Form
Tretin-X Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Tretten Blood Clotting Disorders Medications Blood Clotting Disorders Medications PA Form
Treximet Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Trezix Opioids Opioids PA Form
Triamcinolone Acetonide Topical Corticosteroids Topical Corticosteroids PA Form
Triamcinolone Nasal Nasal Corticosteroids Nasal Corticosteroids PA Form
Trianex Topical Corticosteroids Topical Corticosteroids PA Form
Triazolam Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Tribenzor Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Tricor (fenofibrate 48, 145 mg) Fibric Acid Derivatives Fibric Acids Derivatives PA Form
Trifluoperazine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Triglide Fibric Acid Derivatives Fibric Acid Derivatives PA Form
Trilipix (fenofibrate 45, 135 mg) Fibric Acid Derivatives Fibric Acid Derivatives PA Form
Trimipramine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Trokendi XR Anticonvulsants Anticonvulsants-PA-Form
Trulicity Antidiabetic Agents Antidiabetic Agents PA Form
Tyvaso Pulmonary Hypertension Pulmonary Hypertension PA Form

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Ulesfia 5% Topical Medications Topical Medications (Misc) PA Form
Uloric Anti-Gout Medications Anti-Gout Medications PA Form
Ultravate, Ultravate X Topical Corticosteroids Topical Corticosteroids PA Form

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Valproic Acid Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Diovan-Valsartan HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonist PA Form
Vantas GnRH Agents GnRH Agents PA Form
Varubi Antiemetics Antiemetics PA Form
Vascepa Lovaza-Vascepa Medication PA Request Form
Vectical Topical Medications Topical Medications (Misc) PA Form
Veletri Pulmonary Hypertension Pulmonary Hypertension PA Form
Veltin Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Vena-Bal Mis DHA Brand Name Prescription Vitamins Brand Name Prescription Vitamins PA Form
Venlafaxine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Venoglobulin IVIG, SCIG IVIG, SCIG PA Form
Ventavis Pulmonary Hypertension Pulmonary Hypertension PA Form
Veramyst Nasal Corticosteroids Nasal Corticosteroids PA Form
Verdeso Topical Corticosteroids Topical Corticosteroids PA Form
Veripred Oral Corticosteroids Oral Corticosteroids PA Form
Vesicare Urinary Antispasmodic Medications Urinary Antispasmodic PA Form
Victoza Antidiabetic Agents Antidiabetic Agents PA Form
Victrelis Hepatitis C Hepatitis C PA Form
Viekira Pak Hepatitis C Hepatitis C PA Form
Vigabatrin Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Vigamox Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Viibryd Antidepressants Antidepressants PA Form
Vilazodone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Vimovo NSAIDs-COX2 NSAIDs-COX-2 PA Form
Vimpat Anticonvulsants Anticonvulsants-PA-Form

PBHMI PA Form
Vitamins Brand Name Prescription Vitamins Medication PA Request Form
Vivaglobulin IVIG, SCIG IVIG, SCIG PA Form
Voltaren Gel NSAIDs NSAIDs PA Form
Voriconazole Antifungal Agents Antifungal Agents PA Form
Voriconazole oral Antifungal Agents Antifungal Agents PA Form
Vortioxetine Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Vusion Topical Medications Topical Medications (MIsc) PA From
Vytorin Cholesterol Absorption Inhibitors Cholesterol Absorption Inhibitors PA Form

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Wilate Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form

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Xarelto Anticoagulants (Oral) Anticoagulants (Oral) PA Form
Xartemis XR Opioids Opioids PA Form
Xeljanz Systemic Immunomodulators Systemic Immunomodulators PA Form
Xeomin Botulinum Toxin Botulinum Toxin PA Form
Xerese cream Anti-Herpes Agents Anti-Herpes Agents PA Form
Xgeva Forteo-Prolia-Xgeva Forteo-Prolia-Xgeva PA Form
Xiaflex Xiaflex Xiaflex PA Form
Xifaxan Antibiotics (systemic) policy Antibiotics (systemic) PA Form
Xolair Nucala, Xolair Nucala, Xolair PA Form
Xolegel 2% Topical Medications Topical Medications PA Form
Xyntha Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form

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Zafirlukast Respiratory Medications (Oral) Respiratory Medications (Oral) PA Form
Zaleplon Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Zaltrap Antineoplastic Agents Antineoplastic Agents PA Form
Zarontin Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Zarxio Biologics with Biosimilar Products Biologics with Biosimilar Products PA Form
Zegerid powder packet Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Zelapar Dopamine Agonists/Antiparkinsonian Agents Dopamine Agonists/Antiparkinsonian Agents PA Form
Zelboraf Antineoplastic Agents Antineoplastic Agents PA Form
Zenzedi ADHD Medications ADHD Medications PA Form
Zepatier Hepatitis C Hepatitis C PA Form
Zetia Cholesterol Absorption Inhibitors Cholesterol Absorption Inhibitors PA Form
Zetonna Nasal Corticosteroids Nasal Corticosteroids PA Form
Ziana Acne and Rosacea Agents Acne and Rosacea Agents PA Form
Zioptan Anti-Glaucoma Agents Anti-Glaucoma Agents PA Form
Ziprasidone Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Zipsor NSAIDs-COX2 NSAIDs-COX-2 PA Form
Zithranol Topical Medications Topical Medications (Misc) PA Form
Zohydro ER Opioids Opioids PA Form
Zoladex GnRH Agents GnRH Agents PA Form
Zolmitriptan Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Zolpidem Extended Release Insomnia Agents Insomnia Agents PA form
Zolpidem tartrate Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Zolpimist Insomnia Agents Insomnia Agents PA Form
Zormacton Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Zonegran Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Zonisamide Pediatric Behavioral Health Med Initiative Pediatric Behavioral Health Med Initiative PA Form
Zontivity Antiplatelet Agents Antiplatelet Agents PA Form
Zorbtive Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Zorvolex NSAIDs NSAIDs PA Form
Zostavax Vaccines Vaccines PA Form
Zovirax cream Anti-Herpes Agents Anti-Herpes Agents PA Form
Zubsolv Buprenorphine Products Buprenorphine Products PA Form
Zuplenz Antiemetics Antiemetics PA Form
Zyclara Topical Immunomodulators Topical Immunomodulators PA Form
Zydelig Antineoplastic Agents Antineoplastic Agents PA Form
Zyflo Respiratory Medications (Oral) Respiratory Medications (Oral) PA Form
Zyflo CR Respiratory Medications (Oral) Respiratory Medications (Oral) PA Form
Zykadia Antineoplastic Agents Antineoplastic Agents PA Form
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