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Prior Authorization Forms



PA Form - ACTIQ

PA Form – TRIPTAN Quantity Limit Override

PA Form – Non-Sedating ANTIHISTAMINE

PA Form - BOTOX

PA Form - Brand-Generic Override

PA Form - BYETTA & SYMLIN Step Therapy

PA Form - CELEBREX TWICE DAILY DOSING

PA Form - CONTRACEPTIVES

PA Form – CELEBREX Step Therapy

PA Form - ELIDEL & PROTOPIC Step Therapy

PA Form - ERECTILE DYSFUNCTION

PA Form - FORTEO

PA Form - GROWTH HORMONE

PA Form - LOTRONEX

PA Form - MOBIC Step Therapy

PA Form - ORAL ANTI-FUNGAL

PA Form – PROTON PUMP INHIBITOR Step Therapy/Quantity Limit/Extended Therapy Override

PA Form - PROVIGIL

PA Form - INJECTABLE PSORIASIS AGENTS

PA Form - REVATIO

PA Form - SINGULAIR Step Therapy

PA Form - WEIGHT LOSS

PA Form - WELLBUTRIN

PA Form - WOMENS HEALTH

PA Form - XOLAIR

PA Form - ZELNORM

PA Form – ARB Step Therapy

PA Form - XOPENEX Step Therapy

PA Form - ANTI-EMETIC Quantity Limit Override

PA Form – LUNEST/CHRONIC INSOMNIA Quantity Limit Override