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The Executive Office of, Health and Human Services , State of Rhode Island

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Pharmacy Prior Authorization Program

Prior Authorization (PA) Cheat Sheet

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
- Sample Patient Contract for receiving treatment for Hepatitis C
PA23 - Opioids
PA24 - Yescarta_Kymriah
- PA24 - Yescarta_Kymriah Coverage Guidelines for Modified T-Cell Therapies
General Pharmacy Prior Authorization Form

Executive Office of Health and Human Services
3 West Road
Cranston, RI 02920

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