Pharmacy Prior Authorization Program
Forms
- Prior Authorization for Non-Preferred Drug Form
- PA01 - Modafinil
- PA02 - CNS Stimulants
- PA04 - Weight Loss
- PA05 - Follicle Stimulation
- PA06 - Growth Hormone
- PA09 - Botulinum Toxins
- PA10 - Agents Treating Pulmonary Hypertension
- PA11 - Fuzeon
- PA16 - Chronic Idiopathic Constipation
- PA17 - Qualaquin
- PA18 - Megace ES
- PA20 - Pradaxa
- PA21 - Xifaxan (550mg)
- PA22 - Treatment for Hepatitis C
- PA23 - Opioids
- PA24 - Yescarta_Kymriah
- General Pharmacy Prior Authorization Form