View the complete list of CMS-approved Prior Authorization criteria by plan by clicking on one of the links below:

• Pennsylvania & New Jersey: HMO and PPO Plans Prior Authorizations (2024)
• Pennsylvania: SNP Plans Prior Authorizations (2024)

The following forms are downloadable in PDF format.

2024 Step Therapy

• Pennsylvania: SNP Plans
• Pennsylvania and New Jersey: HMO and PPO Plans

Part D Step Therapy Authorization Forms - The following forms are downloadable in PDF format. 

• Febuxostat - Step Therapy - Medicare
• Livalo - Step Therapy - Medicare
• Nurtec - Step Therapy - Medicare
• Sancuso - Step Therapy - Medicare
• Ubrelvy - Step Therapy - Medicare

Part B Step Therapy