print Home Providers Tools and Resources Prior Authorization Drug Specific Prior Authorizations 2024 (IFP) Drug Specific Prior Authorizations 2024 (IFP) The following forms are downloadable in PDF format. Actimmune Acute Seizure Agents Adempas Albendazole Alpha-1 Proteinase Inhibitors Analgesics, Opioids Long-Acting Analgesics, Opioids Short-Acting Apomorphine Aranesp Arcalyst Austedo Bexarotene 1% gel Botulinum Toxins Brimonidine topical gel Carglumic Acid Cayston Cerdelga CFTR Modulators CGRP Antagonists Chorionic gonadatropin (hCG) Continuous Glucose Monitors (CGMs) Cresemba Cystadane Cystagon Cystaran Dalfampridine Deferasirox Deferiprone Diacomit Dificid Dihydroergotamine Nasal Spray Dimethyl Fumarate-Tecfidera Doptelet Dupixent Early Refills Eligard Emflaza Enbrel Endothelin Receptor Antagonists Epidiolex Evrysdi Fasenra Fentanyl Citrate Transmucosal Lozenge Filgrastim Agents Fingolimod Fuzeon Gattex Growth Hormones Haegarda Humira Icatibant Increlex Ingrezza Isotretinoins Jublia Kerendia Kesimpta Kevzara Ledipasvir-velpatasvir and Harvoni Lucemyra Lupron Depot-PED Mavyret Methyltestosterone Miglustat Mircera Myalept Natpara Nexium packets Nitiptsone Non-formulary Nucala Nuedexta Nurtec Ofev Omnipod Oncology Agents: Oral Orenitram Orilissa Otezla Pegasys Pegfilgrastim Agents Phenoxybenzamine Phosphodiesterase-5 inhibitors Pirfenidone Plegridy Posaconazole Prolia Promacta Pulmozyme Pyrimethamine (Daraprim) Quantity Limit Regranex Repatha Retacrit Rinvoq Rufinamide Rukobia Sapropterin Signifor Simponi Sirturo Sivextro Skyrizi Sodium Phenylbutyrate Sofosbuvir-velpatasvir and Epclusa Somatuline Depot Somavert Sovaldi Stelara Step Therapy Exception Sucraid Synarel Tadalafil for BPH Taltz Tasimelteon Terifunomide Teriparatide Testosterone Replacement Therapy Tetrabenazine Tobramycin inhalation Tolvaptan Topical Retinoids Tremfya Tymlos Tyvaso Uptravi Vemlidy Ventavis Vigabatrin Voriconazole Vosevi Wakefulness Promoting Agents Wegovy Xeljanz Xermelo Xgeva Xifaxan Xolair Xyrem/Xywav Zepatier Zoledronic acid (Reclast) Zometa (zoledronic acid)
