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Pharmacy Questions?

Contact Pharmacy Services:

Phone: 1-888-566-0008
Fax: 1-877-503-7231
Email: pharmacym@bmchp.org

PA Forms & Clinical Guidelines

MassHealth / Commonwealth Care

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
Abstral Opioids Opioids PA Form
Acanya Acne and Rosacea (Topical) 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
Actonel Bisphosphonates Bisphosphonates PA Form
Acuvail Ophthalmic-Anti-Allergy-Anti-Inflammatory Medication PA Request Form
Aczone Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Adapalene Acne and Rosacea (Topical) Acne and Rosacea (Topical) 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
Alamast Opthalmic-Antiallergy-Antiinflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Alfuzosin BPH Medications BPH Medications 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
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
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
Amlodipine-telmisartan Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists
Amlodipine/Atorvastatin HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Ampyra Multiple Sclerosis Multiple Sclerosis PA Form
Amrix Skeletal Muscle Relaxants Skeletal Muscle Relaxants PA Form
Amturnide Direct Renin Inhibitors Direct Renin Inhibitors PA Form
Anacaine Topical Medications Topical Medications (MIsc) PA From
Anadrol Anabolic Steroids Anabolic Steroids PA Form
Anoro Ellipta Respiratory Medications Inhaled Respiratory Medications Inhaled PA Form
Antara (fenofibrate 43, 130 mg) Fibric Acid Derivatives Medication PA Request Form
Anzemet Antiemetics Antiemetics PA Form
Apexicon E Topical Corticosteroids Topical Corticosteroids PA Form
Aplenzin Antidepressants Antidepressants PA Form
Aranesp Erythropoiesis Stimulating Agents Erythropoiesis Stimulating Agents PA Form
Arcalyst Systemic Immunomodulators Systemic Immunomodulators PA Form
Arcapta Respiratory Medications (Inhaled) Respiratory Medications (Inhaled) PA Form
Ascensia Blood Glucose Test Products Blood Glucose Test Strips PA Form
Astepro Nasal Antihistamines Nasal Antihistamines PA Form
Atelvia Bisphosphonates Bisphosphonates PA Form
Atralin Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Aubagio Multiple Sclerosis Multiple Sclerosis PA Form
Avinza Opioids Opioids 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
Azelex Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Azor Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form

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Bactroban 2% Nasal Ointment Topical Medications Topical Medications (Misc) PA Form
Banzel Anticonvulsants Anticonvulsants-PA-Form
Bebulin VH Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Beconase, Beconase AQ Nasal Corticosteroids Nasal Corticosteroids PA Form
BeneFIX Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Benicar Benicar HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Benlysta Systemic Immunomodulators Systemic Immunomodulators PA Form
Benzamycin Gel Pak Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Bepreve Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic Anti-Allergy Anti-Inflammatory PA Form
Berinert Hereditary Angioedema Hereditary Angioedema PA Form
Binosto Bisphosphonates Bisphosphonates PA Form
Bivigam IVIG, SCIG IVIG, SCIG PA Form
Blephamide SOP Ophthalmic Antibiotics Ophthalmic Antibiotics 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
Brisdelle Antidepressants Antidepressants PA Form
Bromday Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic Anti-Allergy Anti-Inflammatory PA Form
Bromfenac Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic Anti-Allergy Anti-Inflammatory PA Form
Buprenorphine Suboxone-Buprenorphine HCL Suboxone-Buprenorphine HCL PA Form
buprenorphine/naloxone tablets Suboxone-Buprenorphine HCL Suboxone-Buprenorphine HCL PA Form
Butrans Opioids Opioids PA Form
Bydureon Antidiabetic Agents Antidiabetic Agents PA Form
Byetta Antidiabetic Agents Antidiabetic Agents PA Form
Bystolic Bystolic-Coreg CR Medication PA Request Form

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Calcitriol Topical Medications Topical Medications (Misc) PA Form
Cambia NSAIDs-COX2 NSAIDs-COX-2 PA Form
Candesartan Candesartan HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Capex Shampoo Topical Corticosteroids Topical Corticosteroids PA Form
Carbaglu Carbaglu Carbaglu PA Form
Cardura XL BPH Medications BPH Medications PA Form
Carimune IVIG, SCIG Medical Benefit PA Form
Carisoprodol Skeletal Muscle Relaxants Medication PA Request Form
Carisprodol 250 mg Skeletal Muscle Relaxants Skeletal Muscle Relaxants PA Form
Celebrex NSAIDs-COX2 NSAIDs-COX-2 PA Form
Cervarix Vaccines Vaccines PA Form
Cesamet Antiemetics Antiemetics 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
Clarinex, Clarinex-D, Clarinex Redi-Tabs Antihistamines Medication PA Request Form
CleverChek Blood Glucose Test Products Blood Glucose Test Strips PA Form
Clindareach Kit Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications 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
Colyte Brand Name PEG Products Medication Prior Authorization Request Form
Compounds Prescription Compounds Prescription Compounds PA Form
Condylox Gel Topical Immunomodulators Topical Immunomodulators
Conzip Tramadol Products Medication PA Request Form
Cordran Topical Corticosteroids Topical Corticosteroids PA Form
Coreg CR Bystolic-Coreg CR Medication PA Request Form
Corifact Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Cortisporin Cream Topical Medications Topical Medications (MIsc) PA From
Crestor HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Cutivate Lotion Topical Corticosteroids Topical Corticosteroids PA Form
Cuvposa Cuvposa Medication PA Request Form
Cyclobenzaprine Extended-Release Skeletal Muscle Relaxants Medication PA Request Form
Cycloset Antidiabetic Agents Antidiabetic Agents PA Form

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Daliresp Respiratory Medications (Oral) Respiratory Medications Oral PA Form
Daytrana ADHD Medications Medication PA Request Form
Derma-Smoothe FS Topical Corticosteroids Topical Corticosteroids PA Form
Desloratadine Antihistamines Antihistamines PA Form
Desonate Topical Corticosteroids Topical Corticosteroids PA Form
Desonil + Plus Topical Corticosteroids Topical Corticosteroids PA Form
Desoximetasone Topical Corticosteroids Topical Corticosteroids PA Form
Desvenlafax Antidepressants Antidepressants PA Form
Dexilant Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Dialyvite Brand Name Prescription Vitamins Medication PA Request Form
Differin Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Dificid Antibiotics (systemic) Antibiotics (systemic) PA Form
Diflorasone diacetate Topical Corticosteroids Topical Corticosteroids PA Form
Diovan-Valsartan HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Dronabinol Antiemetics Antiemetics PA Form
Duac CS Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Dulera Respiratory Medications (Inhaled) Respiratory Medications Inhaled PA Form
Duloxetine Antidepressants Antidepressants PA Form
Durezol Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory 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
Egrifta Egrifta Egrifta 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
Emadine Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Emend Antiemetics Antiemetics PA Form
Enablex Urinary Antispasmodic Medications Medication PA Request Form
Enbrel Systemic Immunomodulators Systemic Immunomodulators PA Form
Epiduo Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Epifoam aerosol Foam 1-1% Topical Medications Topical Medications (MIsc) PA From
Epinastine Ophthalmic Anti-Allergy-Anti-Inflammatory Medication PA Request Form
Epogen Erythropoiesis Stimulating Agents Erythropoiesis Stimulating Agents PA Form
Epoprostenol 600 mg Pulmonary Hypertension Pulmonary Hypertension PA Form
Eprosartan Angiotensin Receptor Antagonists Medication PA Request Form
Ertaczo Topical Medications Topical Medications (MIsc) PA From
Erwinazine Antineoplastic Agents Antineoplastic Agents PA Form
Eszopiclone Insomnia Agents Insomnia Agents PA Form
Euflexxa Viscosupplements Viscosupplements PA Form
Exalgo Opioids Opioids PA Form
Exelderm Topical Medications Topical Medications (MIsc) PA From
Exforge Exforge HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Exjade Iron Chelating Agents Iron Chelating Agents PA Form

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Fanapt Antipsychotics Antipsychotics PA Form
Farxiga Antidiabetic Agents Antidiabetic Agents PA Form
Fazaclo Antipsychotics Antipsychotics PA Form
Feiba VH, NF Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Fenofibrate Fibric Acid Derivatives Medication PA Request Form
Fenoglide Fibric Acid Derivatives Medication PA Request Form
Fentanyal OT Lozenge Opioids Opioids PA Form
Fentanyl Buccal Opioids Opioids PA Form
Fentanyl Buccal Soluble Film Opioids Opioids PA Form
Fentora Opioids Opioids PA Form
Ferriprox Iron Chelating Agents Iron Chelating Agents PA Form
Fexofenadine/pseudoephedrine 12 Hr Antihistamines Antihistamines PA Form
Fexofenadine w/wo Pseudoephedrine Antihistamines Antihistamines PA Form
Fibricor Fibric Acid Derivatives Medication PA Request Form
Finacea Acne and Rosacea (Topical) Acne and Rosacea (Topical) 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
Fluocinolone Oil Topical Corticosteroids Topical Corticosteroids PA Form
Fluvastatin HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Fluvoxamine ER Antidepressants Antidepressants PA Form
Forfivo Antidepressants Antidepressants PA Form
Forteo Forteo-Prolia-Xgeva Forteo-Prolia-Xgeva PA Form
Fosamax D Bisphosphonates Bisphosphonates PA Form
Frova Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form

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GamaSTAN IVIG, SCIG IVIG, SCIG PA Form
Gammagard IVIG, SCIG IVIG, SCIG PA Form
Gammar-P IVIG, SCIG IVIG, SCIG PA Form
Gamunex IVIG, SCIG IVIG, SCIG PA Form
Gardasil Vaccines Vaccines PA Form
Gatifloxacin Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Gelnique Urinary Antispasmodic Medications Medication PA Request Form
Gel-One Viscosupplements Viscosupplements PA Form
Genotropin Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Gilenya Multiple Sclerosis Multiple Sclerosis PA Form
Glucose Test Strips Blood Glucose Test Products Blood Glucose Test Strips PA Form
Glumetza Antidiabetic Agents Antidiabetic Agents PA Form
Golytely Brand Name PEG Products Medication Prior Authorization Request Form
Gralise Anticonvulsants Anticonvulsants-PA-Form
Granisetron Antiemetics Antiemetics PA Form

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Halac Topical Corticosteroids Topical Corticosteroids PA Form
Halog (E) Topical Corticosteroids Topical Corticosteroids PA Form
Halonate Topical Corticosteroids Topical Corticosteroids 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
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
Human Papillomavirus Vaccines Medical Benefit 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

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Ibandronate Bisphosphonates Bisphosphonates PA Form
Ilaris Systemic Immunomodulators Systemic Immunomodulators 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
Intermezzo Insomnia Agents Insomnia Agents PA Form
Intuniv ADHD Medications Medication PA Request Form
Invega Antipsychotics Antipsychotics PA Form
Invokana Antidiabetic Agents Antidiabetic Agents PA Form
Iprivask Iprivask Iprivask PA Form
Iquix Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Itraconazole oral Antifungal Agents Antifungal Agents PA Form
Iveegam En IVIG, SCIG IVIG, SCIG 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
Jentadueto Antidiabetic Agents Antidiabetic Agents PA Form
Juvisync Antidiabetic Agents Antidiabetic Agents PA Form
Juxtapid Homozygous FH Homozygous FH PA Form

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Kalbitor Hereditary Angioedema Hereditary Angioedema PA Form
Kalydeco Kalydeco Kalydeco PA Form
Kapvay ADHD Medications Medication PA Request Form
Kazano Antidiabetic Agents Antidiabetic Agents PA Form
Kenalog aeroso Topical Corticosteroids Topical Corticosteroids PA Form
Ketorolac ophth Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory 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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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
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
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 ER Anticonvulsants Anticonvulsants-PA-Form
Levocetirizine Dihydrochloride Antihistamines Medication PA Request Form
Levofloxacin drops Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Lidocaine 3% Topical Medications Topical Medications (MIsc) PA From
Lidorx 3% Topical Medications Topical Medications (MIsc) PA From
Linzess Amitiza-Linzess Amitiza- Linzess PA Form
Lipofen Fibric Acid Derivatives Medication PA Request Form
Liptrizet Cholesterol Absorption Inhibitors Cholesterol Absorption Inhibitors PA Form
Livalo HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Locoid Topical Corticosteroids Topical Corticosteroids PA Form
Lorzone Skeletal Muscle Relaxants Skeletal Muscle Relaxants
Lotemax Ophthalmic-Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Lunesta Insomnia Agents Medication PA Request Form
Lupron, Lupron Depot, Lupron Depot Ped GnRH Agents GnRH Agents PA Form
Luxiq Topical Corticosteroids Topical Corticosteroids PA Form
Lyrica Anticonvulsants Anticonvulsants-PA-Form

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Makena Makena Makena PA Form
Mefenamic acid NSAIDs-COX2 NSAIDs-COX-2 PA Form
Mentax 1% C Topical Medications Topical Medications (MIsc) PA From
Metaxolone Skeletal Muscle Relaxants Skeletal Muscle Relaxants
Metformin SR Osmotic Antidiabetic Agents Antidiabetic Agents PA Form
Metozolv ODT Metozolv ODT Metozolv ODT
Minocycline HCL Extended Release Acne and Rosacea (Oral) Acne and Rosacea (Oral) PA Form
Mirapex ER Dopamine Agonists Dopamine Agonists 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
Morphine-ER 24HR Opioids Opioids PA Form
Moxeza Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Mozobil Mozobil Mozobil PA Form
Myobloc Botulinum Toxin Botulinum Toxin PA Form
Myrbetriq Urinary Antispasmodic Medications Medication PA Request Form

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Nasonex Nasal Corticosteroids Nasal Corticosteroids PA Form
Natroba Susp Topical Medications Topical Medications (MIsc) PA From
Nesina Antidiabetic Agents Antidiabetic Agents PA Form
Neupro Dopamine Agonists Dopamine Agonists PA Form
Nevanac Ophthalmic Anti-Allergy-Anti-Inflammatory Medication PA Request Form
Nexium; 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% Brand Name Topical Medications Medication PA Request 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
Nucort Topical Corticosteroids Topical Corticosteroids PA Form
Nucynta IR, ER Opioids Opioids PA Form
Nuedexta Nuedexta Nuedexta PA Form
Nulytely Brand Name PEG Products Medication Prior Authorization Request Form
Nutropin Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Nuvigil Modafinil-Nuvigil Modafinil-Nuvigil PA Form

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Octagam IVIG, SCIG Medical Benefit PA Form
Oleptro Antidepressants Antidepressants PA Form
Olux-E Topical Corticosteroids Topical Corticosteroids PA Form
Olysio Hepatitis C Hepatitis C PA Form
Omega-3 Acid Etthyl Esters Lovaza-Vascepa Lovaza-Vascepa PA Form
Omnaris Nasal Corticosteroids Nasal Corticosteroids PA Form
Omnitrope Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Omontys Erythropoiesis Stimulating Agents Erythropoiesis Stimulating Agents 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
Onfi Anticonvulsants Anticonvulsants-PA-Form
Onglyza Antidiabetic Agents Antidiabetic Agents PA Form
Onmel Antifungal Agents Antifungal Agents PA Form
Onsolis Opioids Opioids PA Form
Opsumit Pulmonary Hypertension Pulmonary Hypertension PA Form
Oracea Acne and Rosacea (Oral) Acne and Rosacea (Oral) PA Form
OraPred ODT Oral Corticosteroids Oral Corticosteroids PA Form
Orencia Systemic Immunomodulators Systemic Immunomodulators PA Form
Orphen CDP Skeletal Muscle Relaxants Skeletal Muscle Relaxants PA Form
Orthovisc Viscosupplements Viscosupplements PA Form
Oseni Antidiabetic Agents Antidiabetic Agents PA Form
Osphena Osphena Osphena PA Form
Oxandrolone Anabolic Steroids Anabolic Steroids PA Form
Oxecta Opioids Opioids PA Form
Oxistat Topical Medications Topical Medications (MIsc) PA From
Oxtella XR Anticonvulsants Anticonvulsants-PA-Form
Oxycontin Opioids Opioids PA Form
Oxymorphone-IR Opioids Opioids PA Form
Oxytrol Urinary Antispasmodic Medications Medication PA Request Form

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Pandel Topical Corticosteroids Topical Corticosteroids PA Form
Pataday Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Patanase Nasal Antihistamines Nasal Antihistamines PA Form
Patanol Ophthalmic Anti-Allergy-Anti-Inflammatory Ophthalmic-Anti-Allergy-Anti-Inflammatory PA Form
Pediaderm HC Topical Corticosteroids Topical Corticosteroids PA Form
Pegasys Hepatitis C Hepatitis C PA Form
PEG-Intron Hepatitis C Hepatitis C PA Form
Pennsaid NSAIDs-COX2 NSAIDs-COX-2 PA Form
Pexeva Antidepressants Antidepressants PA Form
Picato Topical Immunomodulators Topical Immunomodulators PA Form
Polygam S/D IVIG, SCIG IVIG, SCIG PA Form
Potiga Anticonvulsants Anticonvulsants-PA-Form
Pradaxa Anticoagulants (Oral) Anticoagulants (Oral) PA Form
Prenate Brand Name Prescription Vitamins Medication PA Request Form
Prevpac Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form
Prilosec powder packet Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Pristiq Antidepressants Antidepressants PA Form
Procrit Erythropoiesis Stimulating Agents Erythropoiesis Stimulating Agents PA Form
Profilnine SD Blood Clotting Disorder Medications Blood Clotting Disorder Medications 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
Protopic Atopic Dermatitis Atopic Dermatitis PA Form
Pylera Polypills-Convenience Packaging Medications Polypills-Convenience Packaging Medications PA Form

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Qnasl Nasal Corticosteroids Nasal Corticosteroids PA Form
Quillivant XR ADHD Medications Medication PA Request Form
Qutenza Qutenza Medication PA Request Form

R

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Ranexa Ranexa Ranexa PA Form
Rapaflo BPH Medications BPH Medications PA Form
Rayos Oral Corticosteroids Oral Corticosteroids PA Form
Rebetol Hepatitis C Hepatitis C PA Form
Recombinate Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Rectiv Rectiv Medication PA Request Form
Refacto Blood Clotting Disorder Medications Blood Clotting Disorder Medications PA Form
Relistor Relistor Relistor 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
Restasis Restasis Restasis PA Form
Retin-A Micro Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Rhinocort Aqua Nasal Corticosteroids Nasal Corticosteroids PA Form
Ribapak Hepatitis C Hepatitis C PA Form
Ribasphere Hepatitis C Hepatitis C 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
Rizatriptan Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Ropinirole XL Dopamine Agonists Dopamine Agonists PA Form
Rybix-ODT Tramadol Products Medication PA Request 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
Savella Savella Savella PA Form
Selrx Topical Medications Topical Medications (Misc) PA Form
Selzentry Antiretroviral Agents Antiretroviral Agents PA Form
Seroquel XR Antipsychotics Antipsychotics PA Form
Serostim Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Sildenafil Pulmonary Hypertension Pulmonary Hypertension PA Form
Silenor Insomnia Agents Insomnia Agents PA Form
Simcor HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors PA Form
Simponi Systemic Immunomodulators Systemic Immunomodulators PA Form
Sklice 0.5% Topical Medications Topical Medications (Misc) PA Form
Solaraze Topical Immunomodulators Topical Immunomodulators PA Form
Solodyn Acne and Rosacea (Oral) Acne and Rosacea (Oral) PA Form
Sorilux Topical Medications Topical Medications (Misc) PA Form
Sovaldi Hepatitis C Hepatitis C PA Form
Spinosad Susp Topical Medications Topical Medications (MIsc) PA From
Sprix NSAIDs-COX2 NSAIDs-COX-2 PA Form
Stavzor Anticonvulsants Anticonvulsants-PA-Form
Stelara Systemic Immunomodulators Systemic Immunomodulators PA Form
Stivarga Antineoplastic Agents Antineoplastic Agents PA Form
Strattera ADHD Medications Medication PA Request Form
Stribild Antiretroviral Agents Antiretroviral Agents PA Form
Suboxone Film Suboxone-Buprenorphine HCL Suboxone-Buprenorphine HCL 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
Symbicort Respiratory Medications (Inhaled) Respiratory Medications Inhaled PA Form
Synagis Synagis Synagis 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
Tazorac Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Tecfidera Multiple Sclerosis Multiple Sclerosis PA Form
Tekamlo Direct Renin Inhibitors Direct Renin Inhibitors PA Form
Tekturna, Tekturna HCT Direct Renin Inhibitors Direct Renin Inhibitors PA Form
Telmisartan-Telmisartan HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists
Temovate Topical Corticosteroids Topical Corticosteroids PA Form
Teveten, 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
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
Toviaz Urinary Antispasmodic Medications Medication PA Request Form
Tracleer Pulmonary Hypertension Pulmonary Hypertension PA Form
Tradjenta Antidiabetic Agents Antidiabetic Agents PA Form
Tramadol Extended-release Tramadol Products Medication PA Request Form
Tranexamic Acid Tranexamic Acid Tranexamic Acid PA Form
Trelstar Depot, LA GnRH Agents GnRH Agents PA Form
Tretinoin Topical (TRET In Oin) Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Tretin-X Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Treximet Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Triamcinolone Nasal Nasal Corticosteroids Medication PA Request Form
Trianex Topical Corticosteroids Topical Corticosteroids PA Form
Tribenzor Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Tricor (fenofibrate 48, 145 mg) Fibric Acid Derivatives Medication PA Request Form
Triglide Fibric Acid Derivatives Medication PA Request Form
Trilipix (fenofibrate 45, 135 mg) Fibric Acid Derivatives Medication PA Request 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
Vectical Topical Medications Topical Medications (Misc) PA Form

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Valsartan HCT Angiotensin Receptor Antagonists Angiotensin Receptor Antagonists PA Form
Vanos Topical Corticosteroids Topical Corticosteroids PA Form
Vantas GnRH Agents GnRH Agents PA Form
Vascepa Lovaza-Vascepa Lovaza-Vascepa PA Form
Veletri Pulmonary Hypertension Pulmonary Hypertension PA Form
Veltin Acne and Rosacea (Topical) Acne and Rosacea (Topical) 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
Vesicare Urinary Antispasmodic Medications Medication PA Request Form
Vfend Antifungal Agents Antifungal Agents PA Form
Victoza Antidiabetic Agents Antidiabetic Agents PA Form
Victrelis Hepatitis C Hepatitis C PA Form
Vigamox Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Viibryd Antidepressants Antidepressants PA Form
Vimovo NSAIDs-COX2 NSAIDs-COX-2 PA Form
Vimpat Anticonvulsants Anticonvulsants-PA-Form
Vitamins Brand Name Prescription Vitamins Medication PA Request Form
Vivaglobulin IVIG, SCIG IVIG, SCIG PA Form
Vivitrol Vivitrol Vivitrol PA Form
Voltaren Gel NSAIDs-COX2 NSAIDs-COX-2 PA Form
Voriconazole oral Antifungal Agents Antifungal Agents PA Form
Vusion Topical Medications Topical Medications (MIsc) PA From
Vytorin Cholesterol Absorption Inhibitors Cholesterol Absorption Inhibitors PA Form
Vyvanse ADHD Medications Medication PA Request 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
Xeomin Botulinum Toxin Botulinum Toxin PA Form
Xerese Topical Antivirals Topical Antivirals PA Form
Xgeva Forteo-Prolia-Xgeva Forteo-Prolia-Xgeva PA Form
Xiaflex Xiaflex Xiaflex PA Form
Xifaxan Antibiotics (systemic) policy Antibiotics (systemic) PA Form
Xiljanz Systemic Immunomodulators Systemic Immunomodulators PA Form
Xolair Xolair 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
Zaltrap Antineoplastic Agents Antineoplastic Agents PA Form
Zanaflex Skeletal Muscle Relaxants Medication PA Request Form
Zegerid powder packet Proton Pump Inhibitors Proton Pump Inhibitors PA Form
Zetia Cholesterol Absorption Inhibitors Cholesterol Absorption Inhibitors PA Form
Zetonna Nasal Corticosteroids Nasal Corticosteroids PA Form
Ziana Acne and Rosacea (Topical) Acne and Rosacea (Topical) PA Form
Zipsor NSAIDs-COX2 NSAIDs-COX-2 PA Form
Zithranol Topical Medications Topical Medications (Misc) PA Form
Zoladex GnRH Agents GnRH Agents PA Form
Zoledronic acid (Reclast) Bisphosphonates Bisphosphonates PA Form
Zolmitriptan Migraine-Specific Medications (Triptans) Migraine-Specific Medications (Triptans) PA Form
Zolpidem Extended Release Insomnia Agents Insomnia Agents PA Form
Zolpimist Insomnia Agents Insomnia Agents PA Form
Zorbtive Growth Hormones and IGF-1 Growth Hormones and IGF1 PA Form
Zostavax Vaccines Vaccines PA Form
Zovirax Topical Antiviral Agents Topical Antivirals PA Form
Zuplenz Antiemetics Antiemetics PA Form
Zyclara Topical Immunomodulators Topical Immunomodulators PA Form
Zyflo Respiratory Medications (Oral) Respiratory Medications (Oral) PA Form
Zyflo CR Respiratory Medications (Oral) Respiratory Medications (Oral) PA Form
Zylet Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Zymaxid Ophthalmic Antibiotics Ophthalmic Antibiotics PA Form
Zyvox Antibiotics (systemic) Antibiotics (systemic) PA Form