Pharmacy prior authorizations

  • PA process
  • Pharmacy benefit criteria (patient-administered)
  • Medical benefit criteria (physician-administered)

Prior authorization process

Fallon Health collaborates with CVS Caremark® (Fallon's Pharmacy Benefit Manager) to implement our prior authorization process. CVS Caremark® reviews pharmacy benefit drugs (patient self-administered drugs, including oral medications), and Fallon reviews medical benefit drugs (physician-administered drugs, including home infusion). Our goal is to make the prior authorization process more efficient to better serve both our providers and members.

Patient-administered drugs (pharmacy benefit)

Our process offers you two ways to submit a prior authorization request for patient self-administered drugs:

  • Electronic prior authorization tool (ePA)
  • Call or fax

Electronic prior authorization tool (ePA)

Fallon and CVS Caremark® have made submitting PAs easy, quick, and convenient, resulting in near real-time decisions.* No faxes. No phone calls. The ePA tool isavailable at no cost to providers and their staff.

Using ePA, you can:

  • Request clinical questions through your intergrated EHR or the ePA website.
  • Answer patient-specific clinical questions electronically and submit for review.

To learn more and to register, go to info.caremark.com/epa. (You’ll need your NPI and DEA numbers.)

*May not result in near real-time decisions for all prior authorization types and reasons.

Call or fax

To serve you quickly and efficiently, we have separate phone and fax numbers for our Medicare, Medicaid and commercial plans.To determine which phone or fax number to use, find the member's plan name on their ID card and locate it in the chart below. When faxing, please use the PA form indicated in the listing on the “Pharmacy benefit criteria (patient-administered)” tab.

Plan name Phone Fax
Medicare
Part D plans
  • Fallon Senior Plan™ HMO
  • Fallon Senior Plan PPO
  • NaviCare®
  • Summit ElderCare®
1-866-239-4707 1-855-633-7673
Medicaid plans
  • Berkshire Fallon Health Collaborative
  • Fallon 365 Care
  • Wellforce Care Plan
1-866-643-5126 1-855-762-5204
Commercial plans
  • Direct Care
  • Fallon Companion Care
  • Select Care
  • Fallon Preferred Care PPO
  • Steward Community Care
  • Tiered Choice
1-866-772-9538 1-888-836-0730
Medicaid and Commercial plans – Specialty Drugs only
  • All Commercial and Medicaid plans
1-866-814-5506 1-866-249-6155
Medicaid and Commercial plans –
Opioid Program only
  • Commercial plans
  • Exchange plans
  • Medicaid plans
1-800-294-5979
1-855-582-2022
1-866-643-5126
1-866-217-5644
1-866-217-5644
1-866-217-5644

Physician-administered drugs (medical benefit)

For physician-administered drugs that require prior authorization, you'll fax a completed Commercial prior authorization form or a Medicare/Medicaid prior authorization form to Fallon at 1-508-791-5101.

Patient-administered drugs (pharmacy benefit)

You can submit a prior authorization request for patient self-administered drugs through CVS/Caremark's ePA tool or by phone or fax. If submitting your request by fax, please use the PA form indicated in the listings below.  Click the "PA process" tab above for phone and fax numbers. 


Important Information regarding the new Massachusetts Standard PA Form and Commercial plan members

Please review the criteria posted on our formulary website prior to completing the PA form or submitting an ePA and provide all relevant data for each part of the criteria. If there is no specific field for the data on the PA form, please use the "Additional information pertinent to this request" field.

Commercial/Medicaid PA forms

Below is a list of patient-administered drugs which require prior authorization and the corresponding PA forms for each drug. Prescribing physicians should request authorization only when the criteria for that specific medication are met. All the documents below are PDF files.

Please refer to our Online Drug Formulary to view drug criteria.

For Commercial member PA requests, you must use the state-mandated standard PA form or use ePA. A link to the standard PA form is provided in the "PA form" column.

Please note: Effective 2/1/2018, we have implemented a new opioid PA process. If the drug you are searching for is not listed by name, please refer to the criteria and PA forms for “Opioid medications (not otherwise listed).”

Drug name

PA form

Abilify (aripiprazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Abilify Maintena (aripiprazole ER injection)

Electronic PA tool ►

PDF form - Medicaid

Abstral (fentanyl)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Acanya (benzoyl peroxide +
clindamycin topical)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Aciphex (rabeprazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Actemra (tocilizumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Acthar (corticotropin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Actimmune (gamma interferon)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Actiq (fentanyl citrate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Aczone (dapsone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Adcirca (tadalafil)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Adempas (riociguat)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Adlyxin (lixisenatide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Admelog (insulin lispro)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Adzenys XR-ODT(amphetamine ER ODT)

Electronic PA tool ►

PDF form - Medicaid

Aerospan (flunisolide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Afinitor (everolimus)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Afrezza (insulin human)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Alecensa (alectinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Alferon N (interferon alfa-N3)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Alsuma (sumatriptan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Alunbrig (brigatinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Alvesco (ciclesonide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ambien CR (zolpidem extended
release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Amerge (naratriptan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Amitiza (lubiprostone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ampyra (dalfampridine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Amrix (cyclobenzaprine extended-release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Anadrol-50 (oxymetholone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Antagon (ganirelix)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Antidepressants

Electronic PA tool ►

PDF form - Medicaid

Antipsychotics

Electronic PA tool ►

PDF form - Medicaid

Apidra (insulin glulisine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Aplenzin (bupropion hydrobromide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Apokyn (apomorpine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Apriso (mesalamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Aptiom (eslicarbazepine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Aranesp (darbepoetin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Arcalyst (rilonacept)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Asmanex (mometasone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Axiron (testosterone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Aubagio (teriflunomide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Austedo (deutetrabenazine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Avonex

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Auryxia (ferric citrate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Banzel (rufinamide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Baraclude (entecavir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Basaglar (insulin glargine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Baxdela (delafloxacin)

Electronic PA tool ►

PDF form - Commercial
PA form - Medicaid

Beconase AQ (beclomethasone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Behavioral Health - Alpha Agonist for members < three years old

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Anti-Anxiety or Mood Stabilizer for members < six years old

Electronic PA tool ►

PDF form -Medicaid

Behavioral Health - Anti-Anxiety Polypharmacy

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Antidepressant, antipsychotic, atomoxetine, or buspirone for members < six years old

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Antidepressant Polypharmacy

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Antipsychotic Polypharmacy

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Cerebral Stimulant for members < three years old

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Cerebral Stimulant Polypharmacy

Electronic PA tool ►

PDF form - Medicaid
PDF form - Medicaid (QL60)
PDF form - Medicaid (QL90)

Behavioral Health - Hypnotic agents in members < six years old

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Medication Polypharmacy

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Mood Stabilizer Polypharmacy

Electronic PA tool ►

PDF form - Medicaid

Behavioral Health - Other hypnotic agents in members < six years old

Electronic PA tool ►

PDF form - Medicaid

Belsomra (suvorexant)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Benlysta (belimumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Benzaclin (benzoyl peroxide + clindamycin topical)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Benzefoam (benzoyl peroxide 5.3%)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Binosto (alendronate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Boniva (ibandronate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Bosulif (bosutinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Bravelle (urofollitropin)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Brilinta (ticagrelor)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Briviact (brivaracetam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Brovana (arformoterol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Bunavail (buprenorphine and naloxone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Buprenorphine tablet

Electronic PA tool ►

PDF form - Medicaid

Buprenorphine/naloxone tablet

Electronic PA tool ►

PDF form - Medicaid

Bydureon (exenatide extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Bydureon Bcise (exenatide extended release)

Electronic PA tool ►

PDF form - Commercial
PA form - Medicaid

Byetta (exenatide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Bystolic (nebivolol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cabometyx (cabozantinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Calomist (cyanocobalamin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Calquence (acalbrutinib)

Electronic PA tool ►

PDF form - Commercial
PA form - Medicaid

Cambia (diclofenac)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Campral (acamprosate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Caprelsa (vandetanib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Carbaglu (carglumic acid)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Carospir (spironolactone)

Electronic PA tool ►

PDF form - Commercial
PA form - Medicaid

Cayston (aztreonam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Celebrex (celecoxib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cerdelga (eliglustat)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cerebral Stimulants and ADHD Medications

Electronic PA tool ►

PDF form - Medicaid

Cesamet (nabilone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cetrotide (cetrorelix)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Cholbam (cholic acid)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Chorionic gonadotropin

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Cialis (tadalafil)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cimzia (certolizumab pegol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Clobex Lotion (clobetasol lotion)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Clobex Shampoo (clobetasol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Clobex Spray (clobetasol propionate spray)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cometriq (cabozantanib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Contraceptives

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid
PDF form - Medicaid (Step Therapy)

Copaxone 40 mg (glatiramer acetate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Copegus (ribavirin)

Electronic PA tool ►

PDF form - Commerical
PDF form - Medicaid

Coreg (carvedilol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Corlanor (ivabradine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cosentyx (secukinumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cotellic (cobimetinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cotempla XR-ODT (methylphenidate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cresemba (isavuconazonium sulfate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Crestor (rosuvastatin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Crinone (progesterone gel)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Cuvposa (glycopyrrolate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cycloset (bromocriptine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cymbalta (duloxetine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Cystaran (cysteamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Daklinza (daclatasvir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Daytrana (methylphenidate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Denavir (penciclovir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Desonate gel (desonide gel)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Desoxyn (methamphetamine) Tablets

Electronic PA tool ►

PDF form - Medicaid

Dificid (fidaxomicin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Diflucan VC (fluconazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Duac Gel (benzoyl peroxide + clindamycin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Dupixent (dupilumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Duzallo (lesinurad-allopurinol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Dyanavel XR (amphetamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Dymista (azelastine and fluticasone nasal spray)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Edluar (zolpidem sublingual)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Effexor XR (venlafaxine hydrochloride)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Effient (prasugrel)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Egrifta (tesamorelin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Emflaza (deflazacort)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Emsam (selegiline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Enbrel (etanercept)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Endometrin (progesterone)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Enstilar (calcipotriene and betamethasone dipropionate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Envarsus XR (tacrolimus)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Epaned (enalapril)

Electronic PA tool ►

PDF form - Medicaid

Epclusa (sofosbuvir/velpatasvir)

Electronic PA tool ►

PDF form - Commerical
PDF form - Medicaid

Epiduo (adapalene/benzoyl
peroxide topical gel)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Epogen (epoetin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Erivedge (vismodegib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Esbriet (pirfenidone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Eucrisa (crisaborole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Evekeo (amphetamine sulfate)

Electronic PA tool ►

PDF form - Medicaid

Evoclin (clindamycin foam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Evzio (naloxone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Excess quantity limits (general)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Extavia (interferon beta 1b)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Extina (ketoconazole foam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Fabior (tazarotene)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Fanapt (iloperidone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Farxiga (dapagliflozen)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Farydak (panobinostat)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Fentora (fentanyl citrate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ferriprox (deferiprone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Fetzima (levomilnacipran)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Firazyr (icatibant)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Flector (diclofenac)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Flonase (fluticasone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Fluoxetine tablets

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Follistim AQ (follitropin)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Forteo (teriparatide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Fortesta (testosterone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Fuzeon (enfuvirtide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Fycompa (perampanel)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ganirelix

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Gattex (teduglutide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Gelnique (oxybutynin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Giazo (balsalazide disodium)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Gilenya (fingolimod)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Gilotrif (afatinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Glyxambi (empagliflozin and linagliptin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Gocovri (amantadine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Gonal-F (follitropin)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Gralise (gabapentin extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Grastek (Timothy Grass Pollen Allergen Extract)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Growth hormone

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Haegarda (C1 Esterase Inhibitor Subcutaneous [Human])

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Halcion (triazolam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Harvoni (ledipasvir and sofosbuvir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Helidac (bismuth metronidazole tetracycline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Hepatitis C patient contract/ information sheet

Electronic PA tool ►

Contract - Commercial

Hepsera (adefovir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Hetlioz (tasimelteon)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Humira (adalimumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Hycamtin (oral topotecan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ibrance (palbociclib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Iclusig (ponatinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Idhifa (enasidenib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ilaris (canakinumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Imbruvica (ibrutinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Imitrex (sumatriptan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Increlex (mecasermin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ingrezza (valbenazine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Inlyta (axitinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Intermezzo (zolpidem tartrate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Intrarosa (prasterone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Intron A (interferon alpha-2b)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Intuniv (guanfacine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Invega (paliperidone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Invokamet (canagliflozin/metformin )

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Invokana (canagliflozin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Jakafi® (ruxolitinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Janumet, Janumet XR (sitagliptin, sitagliptin, and metformin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Januvia (sitagliptin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Jardiance (empagliflozin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Jentadueto, Jentadueto XR (linagliptin/metformin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Juxtapid (lomitapide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kalydeco (ivacaftor)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kapvay (clonidine extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kazano (alogliptin and metformin HCl)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kerydin (tavaborole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Keveyis (dichlorphenamide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kevzara (sarilumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Khedezla (desvenlafaxine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kineret (anakinra)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kisqali (ribociclib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kombiglyze XR (saxagliptin and metformin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Korlym (mifepristone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kuvan (sapropterin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Kynamro (mipomersen)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Latuda (lurasidone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Lazanda (fentanyl nasal spray)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Lenvima (lenvatinib mesylate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Letairis (ambrisentan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Levemir (insulin detemir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Lialda (mesalamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Linzess (linaclotide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Livalo (pitavastatin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Long Acting Insulin/GLP-1 Agonist

Electronic PA tool ►

PDF form - Medicaid

Lonsurf (trifluridine and tipiracil)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Lotronex (alosetron)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Lunesta (eszopiclone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Lupron (leuprolide acetate) - compound

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Luxiq (betamethasone foam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Lynparza (olaparib)

PDF form - Commercial
PDF form - Medicaid

Lyrica (pregabalin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Makena (hydroxyprogesterone caproate injection)

Electronic PA tool ►

DF form - Commercial
PDF form - Medicaid

Mavyret (glecaprevir and pibrentasvir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Mekinist (trametinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Menopur (menotropin)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Methadone

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid
PDF form - Exchange

Methylphenidate ER Products Stimulant Polypharmacy

Electronic PA tool ►

PDF form - Medicaid

Methylphenidate Powder

Electronic PA tool ►

PDF form - Medicaid

Metozolv (metoclopramide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Migranal (dihydroergotamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Mirapex ER (pramipexole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Mircera (methoxy polyethylene glycol-epoetin beta)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Mirvaso (brimonidine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Movantik (naloxegol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Moxatag™ (amoxicillin extended-release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Mozobil (plerixafor)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Myalept (metreleptin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Mydayis (amphetamine-dextroamphetamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Myfortic (mycophenolic acid) - step therapy

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Myrbetriq (mirabegron)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Mytesi (crofelemer)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Naltrexone Powder

Electronic PA tool ►

PDF form - Medicaid

Namzaric (memantine extended release and donepezil)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nasacort AQ (triamcinolone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nascobal (cyanocobalmin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Natesto (testosterone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Natpara (parathyroid hormone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Natroba (spinosad)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nerlynx (neratinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nesina (alogliptin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Neumega (oprelvekin)

Electronic PA tool ►

PDF form - Medicaid

Neupro (rotigotine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nexavar (sorafenib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nexiclon XR (clonidine extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nexium (esomeprazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nilandron (nilutamide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ninlaro (ixazomib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nityr (nitisinone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Non-preferred glucose monitors

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Non-preferred glucose test strips

Electronic PA tool ►

PDF form - Commerical
PDF form - Medicaid

Non-sedating antihistamines (for MassHealth only)

Electronic PA tool ►

PDF form - Medicaid

Noritate (metronidazole)

Electronic PA tool ►

PDF form - Commerical
PDF form - Medicaid

Northera (droxidopa)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Novarel (chorionic gonodatropin)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Novolin (insulin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Novolog Pen (insulin aspart)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Noxafil (posaconazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nuedexta (dextromethorphan/Quinidine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nuplazid (pimavanserin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Nuvigil (armodafinil)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ocaliva (obeticholic acid)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Odomzo (onidegib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ofev (nintedanib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Oleptro (trazodone extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Olux Foam and Olux-E Foam (clobetasol propionate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Olysio (simeprevir)

Electronic PA tool ►

PDF form - Commerical
PDF form - Medicaid

Omeclamox-Pak (omeprazole, clarithromycin, amoxicillin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Omnaris (ciclesonide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Omontys (peginesatide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

OneTouch Test Strips - excess quantity

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Onfi (clobazam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Onglyza (saxagliptin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Onmel (itraconazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Onsolis (fentanyl buccal soluble film)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Onzetra (sumatriptan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Opioids ER - Step Therapy w/ MME Limit and Post Limit

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid
PDF form - Exchange

Opioids IR - Acute Pain Duration Limit w/ MME Limit and Post Limit

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

PDF form - Exchange

Opioids IR - Combo Products Acute Pain Duration Limit

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid
PDF form - Exchange

Opioid medications (not otherwise listed)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid
PDF form - Exchange

Opsumit (macitentan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Oracea (doxycycline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Oralair

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Oravig (miconazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Orencia (abatacept)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Orenitram (treprostinile ER)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Orfadin (nitisinone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Orkambi (lumacaftor/ivacaftor)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Oseni (alogliptin and pioglitazone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Osphena (ospemifene)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Otezla (apremilast)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Otrexup (methotrexate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ovidrel (choriogonadotropin alfa injection)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Ovide (malathion)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Oxandrin (oxandrolone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Oxtellar XR (oxcarbazepine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Pacnex (benzoyl peroxide 7%)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

PEG-Intron, Pegasys (peginterferon alfa-2b, Peginterferon alfa-2a)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Penlac (ciclopirox)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Perforomist (formoterol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Phosphodiesterase-5 inhibitors (Cialis, Levitra, Staxyn, Viagra)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Picato Gel (Ingenol mebutate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Plegridy (peginterferon beta-1a)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Pomalyst (pomalidomide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Potiga (ezogabine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Pradaxa (dabigatran)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Praluent (alirocumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Pregnyl (chorionic gonodatropin)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Prevymis (letermovir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Pristiq (desvenlafaxine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Proamatine (midodrine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Probuphine (buprenorphine subdermal implant)

Electronic PA tool ►

PDF form - Medicaid

Prochieve (progesterone gel)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Procrit (epoetin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Procysbi (cysteamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Promacta (eltrombopag)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Prosom (estazolam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Proton Pump Inhibitors - for adults

Electronic PA tool ►

PDF form - Medicaid

Proton Pump Inhibitors - for children

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Provigil (modafinil)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Prozac 40mg (fluoxetine 40mg)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Prozac Weekly (fluoxetine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Pylera (biskalcitrate/metronidazole/
tetracycline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Qbrelis (linopril)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Qudexy XR (topiramate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Qualaquin (quinine sulfate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Quillivant XR (methylphenidate extended release oral suspension)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ragwitek (Short Ragweed Pollen Allergen Extract)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ranexa (ranolazine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rapaflo (silodosin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rasuvo (methotrexate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ravicti (glycerol phenylbutyrate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rebetol (ribavirin)

Electronic PA tool ►

PDF form - Commerical
PDF form - Medicaid

Rebif (interferon beta 1a)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rectiv (nitroglycerin ointment 0.4%)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Regranex (becaplermin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Relistor (methylnaltrexone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Repatha (evolucumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Repronex (menatropin)

Electronic PA tool ►

PDF form - Commercial
Additional Infertility Worksheet (only accepted when accompanied by a completed Massachusetts Standard PA Form)

Restasis (cyclosporine ophth)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Revatio (sildenafil)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Revlimid (lenalidomide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rexulti (brexpiprazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rhinocort AQ (budesonide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rhofade (oxymetazoline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ribasphere (ribavirin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ristiq (desvenlafaxine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rozerem (ramelteon)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rubraca (rucaparib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rydapt (midostaurin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rytary (carbidopa/levodopa extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Rythmol SR (propafenone extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sabril (vigabatrin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Samsca (tolvaptan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sandostatin (octreotide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Saphris (asenapine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sarafem (fluoxetine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Savaysa (Edoxaban)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Savella (milnacipran)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Seebri (glycopyrrolate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Selzentry (maraviroc)

Electronic PA tool ►

PDF form - Medicaid

Sensipar (cinacalcet)

Electronic PA tool ►

PDF form - Commercial
PDF form- Medicaid

Sernivo (betamethasone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Short-acting agents for insomnia

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Signifor (pasireotide diaspartate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Silenor (doxepin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Siliq (brodalumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Simponi (golimumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Singulair Allergy (montelukast)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sirturo (bedaquiline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sivextro (tedizolid)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Solaraze (diclofenac)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Soliqua (insulin glargine and lixisenatide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Solodyn (minocycline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Somavert (pegvisomant)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sonata (zalpelon)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sorilux (calcipotriene)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sovaldi (sofosbuvir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sporanox (itraconazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sprix (ketorolac tromethamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sprycel (dasatinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Stadol NS (butorphanol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Standard criteria - exception requests for non-formulary medications (merged market only)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Standard criteria - brand with generic available

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Standard criteria - chemotherapy

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Standard criteria - compounds

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Standard criteria - non-formulary

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Standard Criteria - PA with no criteria and off-label

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Stelara (ustekinumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Stivarga (regorafenib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Strattera (atomoxetine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Strensiq (asfotase alfa)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Striant (testosterone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Subsys (fentanyl sublingual spray)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sumavel (sumatriptan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sutent (sunitinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Sylatron (peginterferon alfa-2b)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Symbyax (olanzapine and fluoxetine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Symlin (pramlintide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Symproic (naldemedine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Synjardy (empagliflozin/metformin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Synjardy XR (empagliflozin/metformin extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Syprine (trientine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Taclonex (calcipotriene and betamethasone dipropionate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tafinlar (dabrafenib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tagrisso (osimertinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Taltz (ixekizumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tamiflu (oseltamivir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tanzeum (albiglutide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tarceva (erlotinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tasigna (nilotinib)

PDF form - Commercial
PDF form - Medicaid

Tecfidera (dimethyl fumerate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Technivie (ombitasvir, paritaprevir, ritonavir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tersifoam (selenium sulfide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Testim (testosterone gel)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Thalomid (thalidomide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tivicay (dolutegravir)

Electronic PA tool ►

PDF form - Medicaid

Topical Testosterone Products

Electronic PA tool ►

PDF form - Medicaid

Topicort Spray (desoximetasone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Toradol (ketorolac)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Toujeo (insulin glargine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Toviaz (fesoterodine fumarate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tracleer (bosentan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tradjenta (linagliptin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Trelegy Ellipta (fluticasone-umeclidinium-vilante)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tremfya (guselkumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tresiba (insulin decludec)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tretinoin

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Treximet (sumatriptan/naproxen sodium)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tribenzor (olmesartan, amlodipine, and hydrochlorothiazide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Trintellix (vortioxetine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Triptans - excess quantity limits

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Trokendi (topiramate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Trokendi XR (topiramate XR)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Trulance

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Trulicity (dulaglutide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tudorza (aclidinium)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tykerb (lapatinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tymlos (teriparatide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Tyvaso (treprostinil)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Uceris (budesonide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Uloric (febuxostat)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Uptravi (selexipag)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Valchlor (mechlorethamine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vancocin (vancomycin)

Electronic PA tool ►

PDF form - Commercial
PA form - Medicaid

Vascepa (icosapent ethyl)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vectical (calcitriol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Velphoro (sucroferric oxyhydroxide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Veltin Gel (clindamycin/tretinoin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Venclexta (venetoclax)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Venlafaxine ER tabs

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ventavis (iloprost)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Veramyst (fluticasone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Verdeso (desonide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Veregen (sinecatechins)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Verzenio (abemaciclib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vfend (voriconazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Viberzi (eluxadoline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Victoza (liraglutide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Viekira (ombitasvir/paritaprevir/ritonavir with dasabuvir)

Electronic PA tool ►

PDF form - Commerical
PDF form - Medicaid

Viibryd (vilazodone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vimovo (naproxen and esomeprazole)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vimpat (lacosamide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Viramune XR (nevirapine extended-release)

Electronic PA tool ►

PDF form - Medicaid

Vivlodex (meloxicam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vogelxo (testosterone gel)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vosevi (sofosbuvir,velpatasvir,voxilaprevir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Votrient (pazopanib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vraylar (cariprazine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Vyvanse (lisdexamfetamine dimesylate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Welchol (colesevelam)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xadago (safinamide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xalkori (crizotinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xartemis XR (oxycodone hydrochloride/acetaminophen
extended-release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid
PDF form - Exchange

Xatmep (methotrexate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xeljanz (tofacitinib) and Xeljanz XR (tofacitinib extended-release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xenazine (tetrabenazine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xenical (orlistat)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xerese (acyclovir 5% and hydrocortisone 1%)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xermelo (telotristat ethyl)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xifaxan (rifaximin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xigduo XR (dapagliflozin/metformin ER)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xiidra (lifitegrast solution/drops)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ximino (minocycline extended release)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xopenex, Xopenex HFA (levalbuterol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xtandi (enzalutamide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xultrophy (insulin degludec/liraglutide)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xuriden (uridine triacetate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Xyrem (sodium oxybate)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zanaflex (tizanidine)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zavesca (miglustat)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zecuity (sumatriptan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zejula (niraparib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zelapar (selegiline)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zelboraf (vemurafenib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zembrance (sumatriptan)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zemplar (paricalcitol)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zenzedi (dextroamphetamine)

Electronic PA tool ►

PDF form - Medicaid

Zepatier (elbasvir and grazoprevir)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Ziana Gel (clindamycin/tretinoin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zinbryta (daclizumab)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zioptan (tafluprost)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zithranol cream 1.2% (anthralin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zithranol shampoo (anthralin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zithromax (azithromycin)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zolinza (vorinostat)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zolpimist (zolpidem)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zorvolex (diclofenac)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zovirax (acyclovir) Topical

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zubsolv (buprenorphine.naloxone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zurampic (lesinurad)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zydelig (idelalisib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zyflo (zileuton)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zykadia (ceritinib)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zytiga (abiraterone)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Zyvox (linezolid)

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

All other medications

Electronic PA tool ►

PDF form - Commercial
PDF form - Medicaid

Medicare PA forms

Please refer to our Online Drug Formulary to view drug criteria.

Drug name

PA form

Abilify Injectable (aripiprazole)

Electronic PA tool ►

PDF form

Actimmune (gamma interferon)

Electronic PA tool ►

PDF form
Actiq (fentanyl citrate)

Electronic PA tool ►

PDF form
Adcirca (tadalafil) 

Electronic PA tool ►

PDF form
Adempas (riociguat)

Electronic PA tool ►

PDF form
Afinitor (everolimus)

Electronic PA tool ►

PDF form
Aldurazyme (laronidase)

Electronic PA tool ►

PDF form
Alecensa (alectinib)

Electronic PA tool ►

PDF form
Aliqopa (copanlisib)

Electronic PA tool ►

PDF form
Alunbrig (brigatinib)

Electronic PA tool ►

PDF form
Ampyra (dalfampridine)

Electronic PA tool ►

PDF form
Anadrol-50 (oxymetholone)

Electronic PA tool ►

PDF form
Antidepressants

Electronic PA tool ►

PDF form
Apokyne (apomorphine)

Electronic PA tool ►

PDF form
Aptiom (eslicarbazepine acetate)

Electronic PA tool ►

PDF form
Aralast (alpha-1 proteinase inhibitor)

Electronic PA tool ►

PDF form
Arcalyst (rilonacept)

Electronic PA tool ►

PDF form
Aubagio (teriflunomide)

Electronic PA tool ►

PDF form
Banzel (rufinamide)

Electronic PA tool ►

PDF form
Baraclude (entecavir)

Electronic PA tool ►

PDF form
Bavencio (avelumab)

Electronic PA tool ►

PDF form
Beleodaq (belinostat)

Electronic PA tool ►

PDF form
Benlysta (belimumab)

Electronic PA tool ►

PDF form
Benztropine

Electronic PA tool ►

PDF form
Bosulif (bosutinib)

Electronic PA tool ►

PDF form
Briviact (brivaracetam)

Electronic PA tool ►

PDF form
Byetta (exenatide)

Electronic PA tool ►

PDF form
Cabometyx (cabozantinib)

Electronic PA tool ►

PDF form
Calquence (acalabrutinib)

Electronic PA tool ►

PDF form
Campral (acamprosate)

Electronic PA tool ►

PDF form
Caprelsa (vandetanib)

Electronic PA tool ►

PDF form
Carbaglu (carglumic acid)

Electronic PA tool ►

PDF form
Carisoprodol

Electronic PA tool ►

PDF form
Cayston (aztreonam)

Electronic PA tool ►

PDF form

Cerezyme (imiglucerase)

Electronic PA tool ►

PDF form

Cinryze (C1 inhibitor human)

Electronic PA tool ►

PDF form

Cometriq (cabozantinib)

Electronic PA tool ►

PDF form

Corlanor (ivabradine)

Electronic PA tool ►

PDF form

Cotellic (cobimetinib)

Electronic PA tool ►

PDF form

Crinone (progesterone gel)

Electronic PA tool ►

PDF form

Cubicin (daptomycin)‎

Electronic PA tool ►

PDF form

Cyclobenzaprine

Electronic PA tool ►

PDF form

Cyclophosphamide

Electronic PA tool ►

PDF form

Cystaran (cysteamine ophthalmic solution) 

Electronic PA tool ►

PDF form
Daklinza (daclatasvir)

Electronic PA tool ►

PDF form
Darzalex (daratumumab)

Electronic PA tool ►

PDF form
Digoxin

Electronic PA tool ►

PDF form
Emend (aprepitant)

Electronic PA tool ►

PDF form
Embeda (morphine sulfate and naltrexone HCl)

Electronic PA tool ►

PDF form
Empliciti (elotuzumab)

Electronic PA tool ►

PDF form
Emsam (selegiline)

Electronic PA tool ►

PDF form
Enbrel (etanercept)

Electronic PA tool ►

PDF form
Entresto (sacubitril/valsartan)

Electronic PA tool ►

PDF form
Epoetin

Electronic PA tool ►

PDF form
Erivedge (vismodegib)

Electronic PA tool ►

PDF form
Erleada (apalutamide)

Electronic PA tool ►

PDF form

Erwinaze (asparaginase Erwinia chrysanthemi)

Electronic PA tool ►

PDF form

Esbriet (pirfenidone)

Electronic PA tool ►

PDF form

ESRD Drugs (Access/Anemia/Bone Mineral Metabolism/Cellular Management)

Electronic PA tool ►

PDF form

Fabrazyme (agalsidase)

Electronic PA tool ►

PDF form
Fanapt (iloperidone)

Electronic PA tool ►

PDF form
Farxiga (dapagliflozen)

Electronic PA tool ►

PDF form
Farydak (panobinostat)

Electronic PA tool ►

PDF form
Ferriprox (deferiprone)

Electronic PA tool ►

PDF form
Fetzima (levomilnacipran)

Electronic PA tool ►

PDF form
Firazyr (icatibant)

Electronic PA tool ►

PDF form
Formulary exception

Electronic PA tool ►

PDF form
Forteo (teriparatide)

Electronic PA tool ►

PDF form
Fycompa (perampanel)

Electronic PA tool ►

PDF form
Gattex (teduglutide)

Electronic PA tool ►

PDF form
Gilenya (fingolimod)

Electronic PA tool ►

PDF form
Gilotrif (afatinib)

Electronic PA tool ►

PDF form
Glyburide

Electronic PA tool ►

PDF form
Growth hormone

Electronic PA tool ►

PDF form
Haegarda (C1 Esterase Inhibitor Subcutaneous [Human])

Electronic PA tool ►

PDF form
Hepatitis B vaccine

Electronic PA tool ►

PDF form
Hepsera (adefovir)

Electronic PA tool ►

PDF form
Herceptin (trastuzumab)

Electronic PA tool ►

PDF form
Harvoni (ledipasvir and sofosbuvir)

Electronic PA tool ►

PDF form
Hetlioz (tasimelteon)

Electronic PA tool ►

PDF form
Hospice drugs

Electronic PA tool ►

PDF form
Humira (adalimumab)

Electronic PA tool ►

PDF form
Hydroxyzine

Electronic PA tool ►

PDF form
Hypnotics

Electronic PA tool ►

PDF form
Ibrance (palbociclib)

Electronic PA tool ►

PDF form
Iclusig (ponatinib)

Electronic PA tool ►

PDF form
Idhifa (enasidenib)

Electronic PA tool ►

PDF form
Ilaris (canakinumab)

Electronic PA tool ►

PDF form
Imbruvica (ibrutinib)

Electronic PA tool ►

PDF form
Imfinzi (durvalumab)

Electronic PA tool ►

PDF form
Immune globulin

Electronic PA tool ►

PDF form
Immunosuppressant agents

Electronic PA tool ►

PDF form
Increlex (mecasermin)

Electronic PA tool ►

PDF form
Infusion pump medications

Electronic PA tool ►

PDF form
Ingrezza (valbenazine)

Electronic PA tool ►

PDF form
Inhalation solutions – beta 2 adrenergic agonists and anticholinergics and corticosteroids and mast cell stabilizers

Electronic PA tool ►

PDF form
Inhalation Solutions – Mucolytics

Electronic PA tool ►

PDF form
Inhalation Solutions – Nebupent (pentamidine)

Electronic PA tool ►

PDF form
Inhalation Solutions – Tobramycin

Electronic PA tool ►

PDF form
Injectibles

Electronic PA tool ►

PDF form
Inlyta (axitinib)

Electronic PA tool ►

PDF form
Intron A (interferon alpha-2b)

Electronic PA tool ►

PDF form
Intuniv (guanfacine extended release)

Electronic PA tool ►

PDF form
Invega (paliperidone)

Electronic PA tool ►

PDF form
Iressa (gefitinib)

Electronic PA tool ►

PDF form
Jakafi (ruxolitinib)

Electronic PA tool ►

PDF form
Janumet (sitagliptin/metformin HCl)

Electronic PA tool ►

PDF form
Januvia (sitagliptin)

Electronic PA tool ►

PDF form
Juxtapid (lomitapide)

Electronic PA tool ►

PDF form
Jynarque (tolvaptan)

Electronic PA tool ►

PDF form
Kadcyla (ado-trastuzumab emtansine)

Electronic PA tool ►

PDF form
Kalydeco (ivacaftor)

Electronic PA tool ►

PDF form
Keveyis (dichlorphenamide)

Electronic PA tool ►

PDF form
Keytruda (pembrolizumab)

Electronic PA tool ►

PDF form
Kineret (anakinra)

Electronic PA tool ►

PDF form
Kisqali (ribociclib)

Electronic PA tool ►

PDF form
Korlym (mifepristone)

Electronic PA tool ►

PDF form
Kuvan (sapropterin dihydrochloride)

Electronic PA tool ►

PDF form
Kynamro (mipomersen sodium)

Electronic PA tool ►

PDF form
Kyprolis (carfilzomib)

Electronic PA tool ►

PDF form
Lartruvo (olaratumab) 

Electronic PA tool ►

PDF form
Latuda (lurasidone)

Electronic PA tool ►

PDF form
Lenvima (lenvatinib)

Electronic PA tool ►

PDF form
Letairis (ambrisentan)

Electronic PA tool ►

PDF form
Levemir  (insulin detemir) 

Electronic PA tool ►

PDF form
Lidoderm (lidocaine patch)

Electronic PA tool ►

PDF form
Lonsurf (trifluridine and tipiracil)

Electronic PA tool ►

PDF form
Lotronex (alosetron)

Electronic PA tool ►

PDF form
Lumigan (bimatoprost ophthalmic solution)

Electronic PA tool ►

PDF form
Lumizyme (alglucosidase alfa)

Electronic PA tool ►

PDF form
Lynparza (olaparib)

Electronic PA tool ►

PDF form
Lynparza tablets (olaparib)

Electronic PA tool ►

PDF form
Lyrica (pregabalin)

Electronic PA tool ►

PDF form
Mavyret (glecaprevir and pibrentasvir)

Electronic PA tool ►

PDF form
Megestrol

Electronic PA tool ►

PDF form
Mekinist (trametinib)

Electronic PA tool ►

PDF form
Movantik (naloxegol)

Electronic PA tool ►

PDF form
Mozobil (plerixafor)

Electronic PA tool ►

PDF form
Multaq (dronedarone)

Electronic PA tool ►

PDF form
Mylotarg (gemtuzumab ozogamicin)

Electronic PA tool ►

PDF form
Myrbetriq (mirabegron)

Electronic PA tool ►

PDF form
Naglazyme (galsulfase)

Electronic PA tool ►

PDF form
Natpara (parathyroid horomone)

Electronic PA tool ►

PDF form
Nerlynx (neratinib)

Electronic PA tool ►

PDF form
Neupro (rotigotine)

Electronic PA tool ►

PDF form
Nexavar (sorafenib)

Electronic PA tool ►

PDF form
Ninlaro (ixazomib)

Electronic PA tool ►

PDF form
Nitrofurantoin

Electronic PA tool ►

PDF form
Nityr (nitisinone)

Electronic PA tool ►

PDF form
Northera (droxidopa)

Electronic PA tool ►

PDF form
Noxafil (posaconazole)

Electronic PA tool ►

PDF form
Nucala (mepolizumab)

Electronic PA tool ►

PDF form
Nuedexta (dextromethorphan/Quinidine)

Electronic PA tool ►

PDF form
Nuplazid (pimavanserin)

Electronic PA tool ►

PDF form
Odomzo (sonidegib)

Electronic PA tool ►

PDF form
Ofev (nintedanib)

Electronic PA tool ►

PDF form
Oncaspar (pegaspargase)

Electronic PA tool ►

PDF form
Onfi (clobazam)

Electronic PA tool ►

PDF form
Opdivo (nivolumab)

Electronic PA tool ►

PDF form
Opsumit (macitentan)

Electronic PA tool ►

PDF form
Oral antiemetic agents (except Akynzeo and Emend)

Electronic PA tool ►

PDF form
Oral chemotherapy agents

Electronic PA tool ►

PDF form
Orencia (abatacept)

Electronic PA tool ►

PDF form
Orfadin (nitisinone)

Electronic PA tool ►

PDF form
Orkambi (lumacaftor/ivacaftor) 

Electronic PA tool ►

PDF form
Otezla (apremilast)

Electronic PA tool ►

PDF form
Oxandrin (oxandrolone)

Electronic PA tool ►

PDF form
OxyContin (oxycodone extended-release)

Electronic PA tool ►

PDF form
Parenteral nutrition

Electronic PA tool ►

PDF form
Perjeta (pertuzumab)

Electronic PA tool ►

PDF form
Pomalyst (pomalidomide)

Electronic PA tool ►

PDF form
Potiga (ezogabine)

Electronic PA tool ►

PDF form
Prevymis (letermovir)

Electronic PA tool ►

PDF form
Pristiq (desvenlafaxine)

Electronic PA tool ►

PDF form
Prolia (denosumab)‎

Electronic PA tool ►

PDF form
Promacta (eltrombopag)

Electronic PA tool ►

PDF form
Provigil (modafinil)

Electronic PA tool ►

PDF form
Radicava (edaravone)

Electronic PA tool ►

PDF form
Ranexa (ranolazine)

Electronic PA tool ►

PDF form
Rebif (interferon beta-1a)

Electronic PA tool ►

PDF form
Relistor (methylnaltrexone)

Electronic PA tool ►

PDF form
Remicade (infliximab)

Electronic PA tool ►

PDF form
Repatha (evolocumab)

Electronic PA tool ►

PDF form
Revatio (sildenafil)

Electronic PA tool ►

PDF form
Revlimid (lenalidomide)

Electronic PA tool ►

PDF form
Rexulti (brexpiprazole)

Electronic PA tool ►

PDF form
Risperdal Consta (risperidone)

Electronic PA tool ►

PDF form
Rozerem (ramelteon)

Electronic PA tool ►

PDF form
Rubraca (rucaparib) 

Electronic PA tool ►

PDF form
Rydapt (midostaurin)

Electronic PA tool ►

PDF form
Sabril (vigabatrin)

Electronic PA tool ►

PDF form
Saphris (asenapine maleate)

Electronic PA tool ►

PDF form
Signifor (pasireotide)

Electronic PA tool ►

PDF form
Sirturo (bedaquiline)

Electronic PA tool ►

PDF form
Skeletal muscle relaxants

Electronic PA tool ►

PDF form
Somatuline Depot (lanreotide)

Electronic PA tool ►

PDF form
Sovaldi (sofosbuvir)

Electronic PA tool ►

PDF form
Sprycel (dasatinib)

Electronic PA tool ►

PDF form
Stivarga (regorafenib)

Electronic PA tool ►

PDF form
Strattera (atomoxetine)

Electronic PA tool ►

PDF form
Sutent (sunitinib)

Electronic PA tool ►

PDF form
Sylatron (peginterferon alfa-2b)

Electronic PA tool ►

PDF form
Symlin (pramlintide)

Electronic PA tool ►

PDF form
Synagis (palivizumab)

Electronic PA tool ►

PDF form
Synribo (omacetaxine mepesuccinate)

Electronic PA tool ►

PDF form
Tafinlar (dabrafenib)

Electronic PA tool ►

PDF form
Tagrisso (osimertinib)

Electronic PA tool ►

PDF form
Tarceva (erlotinib)

Electronic PA tool ►

PDF form
Tasigna (nilotinib)

Electronic PA tool ►

PDF form
Tecentriq (atezolizumab)

Electronic PA tool ►

PDF form
Tecfidera (dimethyl fumarate)

Electronic PA tool ►

PDF form
Testim (testosterone gel)

Electronic PA tool ►

PDF form
Thalomid (thalidomide)

Electronic PA tool ►

PDF form
Tracleer (bosentan)

Electronic PA tool ►

PDF form
Travatan Z (travoprost ophthalmic solution)

Electronic PA tool ►

PDF form
Tremfya (guselkumab)

Electronic PA tool ►

PDF form
Trintellix (vortioxetine)

Electronic PA tool ►

PDF form
Tygacil (tigecycline)

Electronic PA tool ►

PDF form
Tykerb (lapatinib)

Electronic PA tool ►

PDF form
Tysabri (natalizumab)

Electronic PA tool ►

PDF form
Uptravi (selexipag)

Electronic PA tool ►

PDF form
Valchlor (mechlorethamine)

Electronic PA tool ►

PDF form
Vancocin (vancomycin)

Electronic PA tool ►

PDF form

Vancomycin IV

Electronic PA tool ►

PDF form

Venclexta (venetoclax)

Electronic PA tool ►

PDF form

Ventavis (iloprost)

Electronic PA tool ►

PDF form

Verzenio (abemaciclib)

Electronic PA tool ►

PDF form

Vfend (voriconazole)

Electronic PA tool ►

PDF form

Vidaza (azacitidine)

Electronic PA tool ►

PDF form

Viibryd (vilazodone)

Electronic PA tool ►

PDF form

Vimpat (lacosamide)

Electronic PA tool ►

PDF form

Virazole

Electronic PA tool ►

PDF form

Vosevi (sofosbuvir/velpatasvir/voxilaprevir)

Electronic PA tool ►

PDF form

Votrient (pazopanib)

Electronic PA tool ►

PDF form

Vraylar (cariprazine)

Electronic PA tool ►

PDF form
Xalkori (crizotinib)

Electronic PA tool ►

PDF form
Xarelto (rivaroxaban)

Electronic PA tool ►

PDF form
Xeljanz, Xeljanz XR (tofacitinib)

Electronic PA tool ►

PDF form
Xenazine (tetrabenazine)

Electronic PA tool ►

PDF form
Xgeva (denosumab)

Electronic PA tool ►

PDF form
Xolair (omalizumab)

Electronic PA tool ►

PDF form
Xtandi (enzalutamide)

Electronic PA tool ►

PDF form
Xyrem (sodium oxybate)

Electronic PA tool ►

PDF form
Yervoy (ipilimumab)

Electronic PA tool ►

PDF form
Yondelis (trabectedin)

Electronic PA tool ►

PDF form
Yonsa (abiraterone acetate)

Electronic PA tool ►

PDF form
Zaltrap (ziv-aflibercept)

Electronic PA tool ►

PDF form
Zejula (niraparib)

Electronic PA tool ►

PDF form
Zelboraf (vemurafenib)

Electronic PA tool ►

PDF form

Zemplar (paricalcitol)

Electronic PA tool ►

PDF form
Zepatier (elbasvir and grazoprevir)

Electronic PA tool ►

PDF form
Zofran (ondansetron)

Electronic PA tool ►

PDF form
Zolinza (vorinostat)

Electronic PA tool ►

PDF form
Zydelig (idelalisib)

Electronic PA tool ►

PDF form

Zykadia (ceritinib)

Electronic PA tool ►

PDF form

Zytiga (abiraterone)

Electronic PA tool ►

PDF form

Zyvox(linezolid)

Electronic PA tool ►

PDF form

Non-formulary medications

Electronic PA tool ►

PDF form

Physician-administered drugs (medical benefit)

For physician-administered drugs that require prior authorization, fax a completed Commercial prior authorization form or a Medicare/Medicaid prior authorization form to Fallon at 1-508-791-5101.


Important Information regarding the new Massachusetts Standard PA Form and Commercial plan members

Please review the criteria posted on our formulary website prior to completing the PA form and provide all relevant data for each part of the criteria. If there is no specific field for the data on the PA form, please use the "Additional information pertinent to this request" field.

Commercial, Medicaid, and Medicare PA forms and worksheets

Below is a list of physician-administered drugs which require prior authorization and the corresponding PA forms for each drug. Prescribing physicians should request authorization only when the criteria for that specific medication are met. All the documents below are PDF files.

Please refer to our Online Drug Formulary to view drug criteria.

For Commercial member PA requests, you must use the state-mandated standard PA form. A link to the standard PA form is provided in the "PA form" column.

Drug name PA form
Acthar (corticotropin)

PA form - Commercial
PA form - Medicaid and Medicare

Actemra (tocilizumab)

PA form - Commercial
PA form - Medicaid and Medicare

Adcetris (brentuximab)

PA form - Commercial
PA form - Medicaid and Medicare

Aliqopa (copanlisib)

PA form - Commercial
PA form - Medicaid and Medicare

Amevive (alefacept)

PA form - Commercial
PA form - Medicaid and Medicare

Aralast (alpha-1 proteinase inhibitor) PA form - Commercial
PA form - Medicaid and Medicare
Aranesp (darbepoetin) PA form - Commercial
PA form - Medicaid and Medicare
Arranon (nelarabine) PA form - Commercial
PA form - Medicaid and Medicare
Arzerra (ofatumumab) PA form - Commercial
PA form - Medicaid and Medicare

Bavencio (avelumab)

PA form - Commercial
PA form - Medicaid and Medicare
Baxdela (delafloxacin) PA form - Commercial
PA form - Medicaid and Medicare
Beleodaq (belinostat) PA form - Commercial
PA form - Medicaid and Medicare
Bendeka (bendamustine hydrochloride) PA form - Commercial
PA form - Medicaid and Medicare
Benlysta (belimumab) PA form - Commercial
PA form - Medicaid and Medicare
Berinert (C1 esterase inhibitor [Human]) PA form - Commercial
PA form - Medicaid and Medicare
Besponsa (inotuzumab ozogamicin) PA form - Commercial
PA form - Medicaid and Medicare
Blincyto (blinatumomab) PA form - Commercial
PA form - Medicaid and Medicare
Botox (botulinium toxin A) PA form - Commercial
PA form - Medicaid and Medicare
Brineura (cerliponase) PA form - Commercial
PA form - Medicaid and Medicare
Cerdelga (eliglustat) PA form - Commercial
PA form - Medicaid and Medicare
Cerezyme (imiglucerase) PA form - Commercial
PA form - Medicaid and Medicare
Cimzia (certolizumab pegol) PA form - Commercial
PA form - Medicaid and Medicare
Cinqair (reslizumab) PA form - Commercial
PA form - Medicaid and Medicare
Cinryze (C1 inhibitor human) PA form - Commercial
PA form - Medicaid and Medicare
Clolar (clofarabine) PA form - Commercial
PA form - Medicaid and Medicare
Cosentyx (secukinumab) PA form - Commercial
PA form - Medicaid and Medicare
Cotellic (cobimetinib) PA form - Commercial
PA form - Medicaid and Medicare
Cresemba (isavuconazonium sulfate) PA form - Commercial
PA form - Medicaid and Medicare
Cyramza (ramucirumab) PA form - Commercial
PA form - Medicaid and Medicare
Dacogen (decitabine) PA form - Commercial
PA form - Medicaid and Medicare
Darzalex (aratumumab) PA form - Commercial
PA form - Medicaid and Medicare
Dysport (abobotulinumtoxin A) PA form - Commercial
PA form - Medicaid and Medicare
Elaprase (idursulfase) PA form - Commercial
PA form - Medicaid and Medicare
Empliciti (elotuzumab) PA form - Commercial
PA form - Medicaid and Medicare
Entyvio (vedolizumab) PA form - Commercial
PA form - Medicaid and Medicare
Epogen (epoetin) PA form - Commercial
PA form - Medicaid and Medicare
Erwinaze (asparaginase) PA form - Commercial
PA form - Medicaid and Medicare
Ethyol (amifostine) PA form - Commercial
PA form - Medicaid and Medicare
Euflexxa (hyaluronate sodium)  PA form - Commercial
PA form - Medicaid and Medicare
Evomela (melphalan) PA form - Commercial
PA form - Medicaid and Medicare
Exondys 51 (eteplirsen) PA form - Commercial
PA form - Medicaid and Medicare
Fabrazyme (agalsidase) PA form - Commercial
PA form - Medicaid and Medicare
Feraheme (ferumoxytol) PA form - Commercial
PA form - Medicaid and Medicare
Fasenra (benralizumab) PA form - Commercial
PA form - Medicaid and Medicare
Fotolyn (pralatrexate) PA form - Commercial
PA form - Medicaid and Medicare
Gel-One (cross-linked hyaluronate) PA form - Commercial
PA form - Medicaid and Medicare
Gelsyn-3 (hyaluronate sodium)  PA form - Commercial
PA form - Medicaid and Medicare
Genvisc (hyaluronate sodium)  PA form - Commercial
PA form - Medicaid and Medicare
Glassia (alpha-1 proteinase inhibitor) PA form - Commercial
PA form - Medicaid and Medicare
Halaven (eribulin) PA form - Commercial
PA form - Medicaid and Medicare
Hizentra (immunoglobulin SCIG) PA form - Commercial
PA form - Medicaid and Medicare
Hyalgan (hyaluronate sodium) PA form - Commercial
PA form - Medicaid and Medicare
Hymovis (hyaluronic acid) PA form - Commercial
PA form - Medicaid and Medicare
HyQvia (immune globulin) PA form - Commercial
PA form - Medicaid and Medicare
Ilaris (canakinumab) PA form - Commercial
PA form - Medicaid and Medicare
Imfinzi (durvalumab) PA form - Commercial
PA form - Medicaid and Medicare
Imlygic (talimogene laherparepvec) PA form - Commercial
PA form - Medicaid and Medicare
Immunoglobulin IVIG and SCIG PA form - Commercial
PA form - Medicaid and Medicare
Inflectra (infliximab-dyyb) PA form - Commercial
PA form - Medicaid and Medicare
Injectafer (ferric carboxymaltose) PA form - Commercial
PA form - Medicaid and Medicare
Intron A (interferon alpha-2b) PA form - Commercial
PA form - Medicaid and Medicare
Istodax (romidepsin) PA form - Commercial
PA form - Medicaid and Medicare
Ixempra (ixabepilone) PA form - Commercial
PA form - Medicaid and Medicare
Jevtana (cabazitaxel) PA form - Commercial
PA form - Medicaid and Medicare
Kadcyla (ado-trastuzumab emtansine) PA form - Commercial
PA form - Medicaid and Medicare
Kalbitor (ecallantide) PA form - Commercial
PA form - Medicaid and Medicare
Kanuma (sebelipase alfa) PA form - Commercial
PA form - Medicaid and Medicare
Kepivance (palifermin) PA form - Commercial
PA form - Medicaid and Medicare
Keytruda (pembrolizumab) PA form - Commercial
PA form - Medicaid and Medicare
Kineret (anakinra) PA form - Commercial
PA form - Medicaid and Medicare
Krystexxa (pegloticase) PA form - Commercial
PA form - Medicaid and Medicare
Kyprolis (carfilzomib) PA form - Commercial
PA form - Medicaid and Medicare
Lartruvo (olaratumab) PA form - Commercial
PA form - Medicaid and Medicare
Lemtrada (alemtuzumab) PA form - Commercial
PA form - Medicaid and Medicare
Mepsevii (vestronidase alfa-vjbk) PA form - Commercial
PA form - Medicaid and Medicare
Mircera (methoxy polyethylene glycol-epoetin beta) PA form - Commercial
PA form - Medicaid and Medicare
Monovisc (hyaluronate sodium) PA form - Commercial
PA form - Medicaid and Medicare
Mozobil (plerixafor) PA form - Commercial
PA form - Medicaid and Medicare
Mylotarg (gemtuzumab) PA form - Commercial
PA form - Medicaid and Medicare
Myobloc (botulinum toxin B) PA form - Commercial
PA form - Medicaid and Medicare
Myozyme (aglucosidase alfa) PA form - Commercial
PA form - Medicaid and Medicare
Naglazyme (galsulfase) PA form - Commercial
PA form - Medicaid and Medicare
Nplate (romiplostim) PA form - Commercial
PA form - Medicaid and Medicare
Nucala (mepolizumab) PA form - Commercial
PA form - Medicaid and Medicare
Ocrevus (Ocrelizumab) PA form - Commercial
PA form - Medicaid and Medicare
Ontak (denileukin diftitox) PA form - Commercial
PA form - Medicaid and Medicare
Opdivo (nivolumab) PA form - Commercial
PA form - Medicaid and Medicare
Orencia (abatacept) PA form - Commercial
PA form - Medicaid and Medicare
Orthovisc (hyaluronic acid) PA form - Commercial
PA form - Medicaid and Medicare
Panhematin (hemin) PA form - Commercial
PA form - Medicaid and Medicare
Parsabiv (etelcalcetide) PA form - Commercial
PA form - Medicaid and Medicare
Perjeta (pertuzumab) PA form - Commercial
PA form - Medicaid and Medicare
Plasma volume expander PA form - Commercial
PA form - Medicaid and Medicare
Portrazza (necitumumab) PA form - Commercial
PA form - Medicaid and Medicare
Prevymis (letermovir) PA form - Commercial
PA form - Medicaid and Medicare
Procrit (epoetin) PA form - Commercial
PA form - Medicaid and Medicare
Prolastin (alpha-1 proteinase inhibitor) PA form - Commercial
PA form - Medicaid and Medicare
Prolia (denosumab) PA form - Commercial
PA form - Medicaid and Medicare
Radicava (edaravone) PA form - Commercial
PA form - Medicaid and Medicare
Remicade (infliximab) PA form - Commercial
PA form - Medicaid and Medicare
Renflexis (infliximab-abda) PA form - Commercial
PA form - Medicaid and Medicare
Rituxan (rituximab) PA form - Commercial
PA form - Medicaid and Medicare
Rituxan Hycela (rituximab-hyaluronidase human) PA form - Commercial
PA form - Medicaid and Medicare
Ruconest (C1 esterase inhibitor[recombinant]) PA form - Commercial
PA form - Medicaid and Medicare
Sandostatin (octreotide) PA form - Commercial
PA form - Medicaid and Medicare
Simponi (golimumab) PA form - Commercial
PA form - Medicaid and Medicare
Simponi Aria (golimumab)

PA form - Commercial
PA form - Medicaid and Medicare

Soliris (eculizumab) PA form - Commercial
PA form - Medicaid and Medicare
Somatuline Depot (lanreotide) PA form - Commercial
PA form - Medicaid and Medicare
Spinraza (nusinersen) PA form - Commercial
PA form - Medicaid and Medicare
Standard criteria - brand with generic available PA form - Commercial
PA form - Medicaid and Medicare
Standard criteria - chemotherapy PA form - Commercial
PA form - Medicaid and Medicare
Standard criteria - compounds PA form - Commercial
PA form - Medicaid and Medicare
Standard Criteria - PA with no criteria and off-label PA form - Commercial
PA form - Medicaid and Medicare
Stelara (ustekinumab) PA form - Commercial
PA form - Medicaid and Medicare
Supartz (sodium hyaluronate) PA form - Commercial
PA form - Medicaid and Medicare
Sylvant (siltuximab) PA form - Commercial
PA form - Medicaid and Medicare
Synagis (palivizumab) PA form - Commercial
Synagis Enrollment Form - Medicaid and Medicare
Synribo (omacetaxine mepesuccinate) PA form - Commercial
PA form - Medicaid and Medicare
Synvisc and Synvisc-One (hylan polymers A and B) PA form - Commercial
PA form - Medicaid and Medicare
Tecentriq (atezolizumab) PA form - Commercial
PA form - Medicaid and Medicare
Testopel (testosterone) PA form - Commercial
PA form - Medicaid and Medicare
Treanda (bendamustine hydrochloride) PA form - Commercial
PA form - Medicaid and Medicare
Triptodur (triptorelin) PA form - Commercial
PA form - Medicaid and Medicare
Tygacil (tigecycline)

PA form - Commercial
PA form - Medicaid and Medicare

Tysabri (natalizumab)

PA form - Commercial
PA form - Medicaid and Medicare

Vabomere (meropenem and vaborbactam) PA form - Commercial
PA form - Medicaid and Medicare
Vectibix (panitumumab) PA form - Commercial
PA form - Medicaid and Medicare
Vidaza (azacitidine) PA form - Commercial
PA form - Medicaid and Medicare
Vpriv (velaglucerase)

PA form - Commercial
PA form - Medicaid and Medicare

Vyxeos (daunorubicin-cytarabine)

PA form - Commercial
PA form - Medicaid and Medicare

Xeomin (incobotulinumtoxin A)

PA form - Commercial
PA form - Medicaid and Medicare

Xgeva (denosumab)

PA form - Commercial
PA form - Medicaid and Medicare

Xiaflex (collagenase clostridium histolyticum)

PA form - Commercial
PA form - Medicaid and Medicare

Xigris (drotrecogin alfa)

PA form - Commercial
PA form - Medicaid and Medicare

Xofigo (radium Ra 223 dichloride)

PA form - Commercial
PA form - Medicaid and Medicare

Xolair (omalizumab)

PA form - Commercial
PA form - Medicaid and Medicare

Yervoy (ipilimumab)

PA form - Commercial
PA form - Medicaid and Medicare

Yondelis (trabectedin)

PA form - Commercial
PA form - Medicaid and Medicare

Zaltrap (ziv-aflibercept)

PA form - Commercial
PA form - Medicaid and Medicare

Zemaira (alpha-1 antiproteinase inhibitor)

PA form - Commercial
PA form - Medicaid and Medicare

Zilretta (triamcinolone)

PA form - Commercial
PA form - Medicaid and Medicare

Zinplava (bezlotoxumab)

PA form - Commercial
PA form - Medicaid and Medicare

Zostavax (zoster vaccine live)

PA form - Commercial
PA form - Medicaid and Medicare

Zyvox (linezolid)

PA form - Commercial
PA form - Medicaid and Medicare

If the drug you are looking for is not listed, please use the Commercial prior authorization form or a Medicare/Medicaid prior authorization form

CVS Caremark is a registered trademark of CVS Pharmacy, Inc. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information.