Prescription Drug Forms

Prior Authorization

5 HI1 Agonist Post Limit
Abilify®
Abilify® (For Maryland Only)
Abraxane®
Abstral®
Abraxane® (For Maryland Only)
Accu-Chek Aviva Plus Test Strips
Accu-Chek Strips and Kits 4
Accu-Chek Strips and Kits 4 (For Maryland Only)
Acetemra®
Acetemra® (For Maryland Only)
Acthar®
Acthar® (For Maryland Only)
Actimmune®
Actimmune® (For Maryland Only)
Actiq®
Actos
Actos (For Maryland Only)
Adagen®
Adcirca®
Adderall XR
Adderall XR (For Maryland Only)
Adempas®
Adrenaclick®
Adrenaclick® (For Maryland Only)
Advate®
Advate® (For Maryland Only)
Advicor®
Advicor® (For Maryland Only)
Aerospan®
Aerospan® (For Maryland Only)
Afinitor®
Afinitor® (For Maryland Only)
Aldurazyme®
Alimta®
Alimta® (For Maryland Only)
Alphanate®
Alphanate® (For Maryland Only)
Alphanine SD®
Alprolix®
Alsuma®
Altoprev®
Altoprev® (For Maryland Only)
Alvesco®
Alvesco® (For Maryland Only)
Amerge®
Amitiza®
Amitiza® (For Maryland Only)
Ampyra®
Ampyra® (For Maryland Only)
Amrix®
Amrix® (For Maryland Only)
Androdgel®
Androdgel® (For Maryland Only)
Angiotensin II Receptor Antagonists Combo FA-EXC®
Angiotensin II Receptor Antagonists Combo FA-EXC® (For Maryland Only)
Angiotensin II Receptor Antagonists FA-EXC®
Angiotensin II Receptor Antagonists FA-EXC® (For Maryland Only)
Apexicon E FA-EXC®
Apexicon E FA-EXC® (For Maryland Only)
Apidra FA-EXC®
Apidra FA-EXC® (For Maryland Only)
Aralast NP®
Arthrotec FA-EXC®
Arthrotec FA-EXC® (For Maryland Only)
Asacol-HD FA-EXC®
Asacol-HD FA-EXC® (For Maryland Only)
AAT Deficiency
Atacand®
Atacand® (For Maryland Only)
Atacand® HCT
Atacand® HCT (For Maryland Only)
Apokyn®
Aranesp®
Arcalyst®
Atralin®
Aubagio®
Aubagio® (For Maryland Only)
Avastin®
Avastin® (For Maryland Only)
Avita®
Avonex®
Avonex® (For Maryland Only)
Azacitidine®
Beconase AQ®
Bayer Contour Test Strip®
Bebulin VH®
Beconase AQ® (For Maryland Only)
Bendeka®
Bendeka® (For Maryland Only)
Benefix®
Benlysta®
Benlysta® (For Maryland Only)
Berinert-Cinryze®
Berinert-Cinryze® (For Maryland Only)
Betaseron®
Betaseron® (For Maryland Only)
Bethkis®
Bexarotene®
Bivigam®
Bivigam® (For Maryland Only)
Blincyto®
Biguanides (FA-EXC)®
Biguanides (FA-EXC)® (For Maryland Only)
Bosulif®
Bosulif® (For Maryland Only)
Botox®
Botox® (For Maryland Only)
Bravelle®
Breeze 2 Test Strips (FA-EXC)®
Breeze 2 Test Strips (FA-EXC)® (For Maryland Only)
Bydureon®
Bydureon® (For Maryland Only)
Byetta (FA-EXC)®
Byetta (FA-EXC)® (For Maryland Only)
Buphenyl®
Butorphanol®
Capecitabine®
Capecitabine® (For Maryland Only)
Carac®
Carac® (For Maryland Only)
Cardizem®
Cardizem® (For Maryland Only)
Cardizem® CD
Cardizem® CD (For Maryland Only)
Cardizem® LA
Cardizem® LA (For Maryland Only)
Carimune NF®
Carimune NF® (For Maryland Only)
Caprelsa®
Caprelsa® (For Maryland Only)
Carbaglu®
Cayston®
Cerdelga®
Cerezyme®
Cetrotide®
Cholbam®
Cialis®
Cimzia®
Cimzia® (For Maryland Only)
Cinryze®
Clobetasol® Spray
Clobetasol® Spray (For Maryland Only)
Clobex® Spray
Clobex® Spray (For Maryland Only)
Cometriq®
Compounded Drug Products®
Contour Test Strips
Contour Next Test Strips amd Kits 4
Contour Next Test Strips amd Kits 4 (For Maryland Only)
Contour Strips amd Kits 4
Contour Strips amd Kits 4 (For Maryland Only)
Copaxone
Copaxone (For Maryland Only)
Copegus®
Corifact®
Cosentyx®
Cosentyx® (For Maryland Only)
Cotellic®
Cymbalta®
Cymbalta® (For Maryland Only)
Cystagon®
Cystaran®
Cytogam®
Daklinza®
Delzicol®
Delzicol® (For Maryland Only)
Detrol LA®
Detrol LA® (For Maryland Only)
Diabetic Test Strips – Atypical (FA-PA)
Diovan®
Diovan® (For Maryland Only)
Diovan® HCT
Diovan® HCT (For Maryland Only)
Docefrez®
Docefrez® (For Maryland Only)
Docetaxel®
Docetaxel® (For Maryland Only)
DPP-4 Inhibitors Combinations (FA-EXC)®
DPP-4 Inhibitors Combinations (FA-EXC)® (For Maryland Only)
DPP-4 Inhibitors (FA-EXC)®
DPP-4 Inhibitors (FA-EXC)® (For Maryland Only)
Duexis (FA-EXC)®
Duexis (FA-EXC)® (For Maryland Only)
Dymista (FA-EXC)®
Dymista (FA-EXC)® (For Maryland Only)
Dysport®
Dysport® (For Maryland Only)
Edarbi®
Edarbi® (For Maryland Only)
Edarbyclor®
Edarbyclor® (For Maryland Only)
Egrifta®
Elaprase®
Elelyso®
Eligard®
Eloctate®
Eloctate® (For Maryland Only)
Eloxatin®
Eloxatin® (For Maryland Only)
Enbrel®
Enbrel® (For Maryland Only)
Entresto®
Entyvio®
Entyvio® (For Maryland Only)
Epogen®
epoprosteol®
Erbitux®
Erbitux® (For Maryland Only)
Erivedge®
Esbriet®
Euflexxa®
Euflexxa® (For Maryland Only)
Exforge®
Exforge® (For Maryland Only)
Exforge® HCT
Exforge® HCT (For Maryland Only)
Exjade®
Extavia®
Extavia® (For Maryland Only)
Eylea®
Fabior®
Fabrazyme®
Farxiga (FA-EXC)®
Farxiga (FA-EXC)® (For Maryland Only)
Farydak®
Farydak® (For Maryland Only)
Feiba®
Fentanyl Cirtate Oral Tra®
Fentora®
Ferriprox®
Firazyr®
Firmagon®
Flebogamma®
Flebogamma® (For Maryland Only)
Flector (FA-EXC)®
Flector (FA-EXC)® (For Maryland Only)
Flolan®
Fluorouracil® Cream 0.5%
Fluorouracil® Cream 0.5% (For Maryland Only)
Follistim AQ®
Forteo®
Forteo® (For Maryland Only)
Fortament®
Fortament® (For Maryland Only)
Fortesta®
Fortesta® (For Maryland Only)
Fosrenol®
Fosrenol® (For Maryland Only)
Freestyle Strips and Kits 4®
Freestyle Strips and Kits 4® (For Maryland Only)
Freestyle Test Strips
Freestyle Test Strips
Frova® Post Limit
Fuzeon®
GamaSTAN S/D®
GamaSTAN S/D® (For Maryland Only)
Gammagard®
Gammagard® (For Maryland Only)
Gammaked®
Gammaked® (For Maryland Only)
Gammaplex®
Gammaplex® (For Maryland Only)
Gamunex®
Gamunex® (For Maryland Only)
Ganirelix Acetate®
Gattex®
Gel-One®
Gel-One® (For Maryland Only)
Gemzar®
Gemzar® (For Maryland Only)
Genotropin®
Genotropin® (For Maryland Only)
Gilenya®
Gilenya® (For Maryland Only)
Gilotrif®
Glassia®
Glatopa®
Glatopa® (For Maryland Only)
Gleevec®
Glumetza®
Glumetza® (For Maryland Only)
GONAL-F®
GONAL-F RFF®
Granix®
Harvoni®
Hecoria (FA-EXC)®
Hecoria (FA-EXC)® (For Maryland Only)
Helixate®
Helixate® (For Maryland Only)
Hemofil M®
Hemofil M® (For Maryland Only)
Hetlioz®
Hereditary Angioedema
Herceptin®
Herceptin® (For Maryland Only)
Hizentra®
HMG-CoA Reductase Inhibitors (FA-EXC)®
HMG-CoA Reductase Inhibitors (FA-EXC)® (For Maryland Only)
Humalog (FA-EXC)®
Humalog (FA-EXC)® (For Maryland Only)
Humalog Mix 50/60) (FA-EXC)®
Humalog Mix 50/60)(FA-EXC)® (For Maryland Only)
Humalog Mix 75/25) (FA-EXC)®
Humalog Mix 75/25)(FA-EXC)® (For Maryland Only)
Humate-P®
Humate-P® (For Maryland Only)
Humatrope®
Humira®
Humira® (For Maryland Only)
Humulin 70/30 (FA-EXC)®
Humulin 70/30 (FA-EXC)® (For Maryland Only)
Humulin N (FA-EXC)®
Humulin N (FA-EXC)® (For Maryland Only)
Humulin R (FA-EXC)®
Humulin R (FA-EXC)® (For Maryland Only)
Hyalgan®
Hyalgan® (For Maryland Only)
Hycamtin®
HyQvia®
Ibrance®
Iclusig®
Ilaris®
Ilaris® (For Maryland Only)
Imbruvica®
Imbruvica® (For Maryland Only)
Imitrex®
Increlex®
Incruse Ellipta®
Incruse Ellipta® (For Maryland Only)
Inflectra®
Inflectra® (For Maryland Only)
Influenza Treatment
Inlyta®
Inlyta® (For Maryland Only)
Insomnia Agents (FA-EXC)
Insomnia Agents (FA-EXC)(For Maryland Only)
Intermezzo®
Intermezzo® (For Maryland Only)
Intron A®
Intron A® (For Maryland Only)
Intuniv®
Intuniv® (For Maryland Only)
Invokamet®
Invokamet® (For Maryland Only)
Invokana®
Invokana® (For Maryland Only)
Iressa®
Ixempra®
Jadenu®
Jakafi®
Jakafi® (For Maryland Only)
Jalyn (FA-EXC)®
Jalyn (FA-EXC)® (For Maryland Only)
Juxtapid®
Juxtapid® (For Maryland Only)
Kadcyla®
Kalbitor®
Kalbitor® (for Maryland only)
Kalydeco®
Kazano®
Kazano® (For Maryland Only)
Kineret®
Kitabis Pak®
Koate-DVI®
Koate-DVI® (For Maryland Only)
Kogenate FS®
Kogenate FS® (For Maryland Only)
Korlym®
Komibiglyze XR®
Komibiglyze XR® (For Maryland Only)
Kuvan®
Kynamro®
Kynamro® (For Maryland Only)
Lastacaft (FA-EXC)®
Lastacaft (FA-EXC)® (For Maryland Only)
Lazanda®
Lemtrada®
Lemtrada® (For Maryland Only)
Lenvima®
Lenvima® (For Maryland Only)
Lescol XL®
Lescol XL® (For Maryland Only)
Letairis®
Levitra (FA-EXC)®
Levitra (FA-EXC)® (For Maryland Only)
Leuprolide Acetate
Lipitor®
Lipitor® (For Maryland Only)
Liptruzet®
Liptruzet® (For Maryland Only)
Livalo®
Livalo® (For Maryland Only)
Lonsurf®
Lovaza®
Lucentis®
Lumigan (FA-EXC)®
Lumigan (FA-EXC)® (For Maryland Only)
Lumizyme®
Lunesta®
Lunesta® (For Maryland Only)
Lupron®, Hormonal
Leukine®
Lynparza®
Lynparza® (For Maryland Only)
Macugen®
Matzim LA®
Matzim LA® (For Maryland Only)
Mekinist®
Mekinist® (For Maryland Only)
Menopur®
Mircera®
Mitoxantrone®
Moderiba®
Monoclate-P®
Monoclate-P® (For Maryland Only)
Mononine®
Monovisc®
Monovisc® (For Maryland Only)
Myalept®
Myobloc®
Myozyme®
Naglazyme®
Naprelan (FA-EXC)®
Naprelan (FA-EXC)® (For Maryland Only)
Nasal Steroids (FA-EXC)®
Nasal Steroids (FA-EXC)® (For Maryland Only)
Natpara®
Natesto®
Natesto® (For Maryland Only)
Nesina®
Nesina® (For Maryland Only)
Neulasta®
Neumega®
Neupogen®
New to Market Drugs;
New to Market Drugs (For Maryland Only)
Ninlaro®
Norditropin Flexpro®
Northera®
Noritate®
Noritate® (For Maryland Only)
Nesina® (For Maryland Only)
Nexavar®
Nexavar® (For Maryland Only)
NovoSeven RT®
NovoSeven RT® (For Maryland Only)
Norvasc (FA-EXC)®
Norvasc (FA-EXC)® (For Maryland Only)
Nplate®
Nplate® (For Maryland Only)
Nutropin AQ®
Octagam®
Octagam® (For Maryland Only)
Octreotide Acetate®
Octreotide Acetate® (For Maryland Only)
Odomzo®
Ofev®
Oleptro
Oleptro (For Maryland Only)
Olux-E (FA-EXC)
Olux-E (FA-EXC) (For Maryland Only)
Olysio®
Omanaris
Omanaris (For Maryland Only)
Omega 3 Fatty Acids
Omntrope
Omntrope (For Maryland Only)
Onglyza
Onglyza (For Maryland Only)
Onsolis®
Opsumit®
Oral Pain Meds
Orencia®
Orencia® (For Maryland Only)
Orenitram®
Orkambi®
Orthovisc®
Orthovisc® (For Maryland Only)
Oseni
Oseni (For Maryland Only)
Orfadin®
Otezla®
Otezla® (For Maryland Only)
Otrexup®
Otrexup® (For Maryland Only)
Ovidrel®
Oxycontin® Post Limit
Oxytrol
Oxytrol (For Maryland Only)
Pegasys®
Peg-Intron®
Pennsaid
Pennsaid (For Maryland Only)
Perjeta®
Plavix
Plavix (For Maryland Only)
Plegridy®
Plegridy® (For Maryland Only)
Pomalyst®
Pomalyst® (For Maryland Only)
Praluent®
Pregnyl®
Prevacid
Prevacid (For Maryland Only)
Privigen®
Privigen® (For Maryland Only)
Procrit®
Procysbi®
Procysbi® (For Maryland Only)
Prolastin-C®
Prolia®
Prolia® (For Maryland Only)
Promacta®
Promacta® (For Maryland Only)
Protonix
Protonix (For Maryland Only)
Proton Pump Inhibitors (FA-EXC)®
Proton Pump Inhibitors (FA-EXC)® (Fort Maryland Only)
Provenge® (For Maryland Only)
Provenge®
Proventil® HFA
Proventil® HFA (For Maryland Only)
Pulmozyme®
QNSL® HFA
QNSL® HFA (For Maryland Only)
QSYMIA® HFA
QSYMIA® HFA (For Maryland Only)
Rasuvo®
Rasuvo® (For Maryland Only)
Ravicti®
Ravicti® (For Maryland Only)
Rayos (FA-EXC)®
Rayos (FA-EXC)® (For Maryland Only)
Rebetol®
Reclast®
Reclast® (For Maryland Only)
Recombinate®
Recombinate® (For Maryland Only)
Regranix®
Relistor®
Relistor® (For Maryland Only)
Remicade®
Remicade® (For Maryland Only)
Remodulin®
Repatha®
Replax Post Limit®
Repronex®
Retin-A®
Revatio®
Revlimid®
Revlimid® (For Maryland Only)
Rebif (FA-EXC)®
Rebif (FA-EXC)® (For Maryland Only)
Rhinocort Aquia®
Rhinocort Aquia® (For Maryland Only)
RiaSTAP®
Ribasphere®
Ribavirin®
Riomet®
Riomet® (For Maryland Only)
Rituxan®
Rituxan® (For Maryland Only)
Rixubis®
Rozerem®
Rozerem® (For Maryland Only)
Rubraca®
Ruconest®
SABAs (FA-EXC)®
SABAs (FA-EXC)® (For Maryland only)
Sabril®
Sabril® (For Maryland Only)
Saizen®
Samsca®
Sandostatin®
Sandostatin® (For Maryland Only)
Serostim®
Serostim® (For Maryland Only)
Sensipar®
Signifor®
Sildenafil®
Simponi®, Simponi Aria®
Simponi®, Simponi Aria® (For Maryland Only)
Sodium Phenylbutyrate
Soliris®
Solodyn®
Solodyn® (For Maryland Only)
Somatuline Depot®
Somavert®
Somavert® (For Maryland Only)
Sovaldi®
Spinraza®
Sprycel®
Stelara®
Stelara® (For Maryland Only)
Stimate®
Stivarga®
Stivarga® (For Maryland Only)
Subsys®
Supartz®
Supartz® (For Maryland Only)
Sutent®
Sutent® (For Maryland Only)
Sylatron®
Symbicort (FA-EXC)®
Symbicort (FA-EXC)® (For Maryland Only)
Synagis®
Tafinlar®
Tamiflu Post Limit®
Taltz®
Tarceva®
Tarceva® (For Maryland Only)
Targretin®
Tasigna®
Tasigna® (For Maryland Only)
Taxotere®
Taxotere® (For Maryland Only)
Tazorac®
Tecfidera®
Tecfidera® (For Maryland Only)
Technivie®
Temodar®
Temozolomide®
Test Strips (Non-One Touch Brands)
Test Strips (Non-One Touch Brands) (For Maryland Only)
Testim®
Testim® (For Maryland Only)
Testosterone Gel 1% 5
Testosterone Gel 1% 5 (For Maryland Only)
Testosterone Products (FA-EXC)
Testosterone Products (FA-EXC) (For Maryland Only)
Tetrabenazine®
Teveten®
Teveten® (For Maryland Only)
Teveten® HCT
Teveten® HCT (For Maryland Only)
Tev-Tropin®
Tev-Tropin® (For Maryland Only)
Thalomid®
Thalomid® (For Maryland Only)
Tikosyn®
TOBI®
Tobramycin®
Toviaz®
Toviaz® (For Maryland Only)
Tracleer®
Treanda®
Treanda® (For Maryland Only)
Trelstar®
Tretten®
Tretin-X®
Treximet Post Limit®
Tricor (FA-EXC)®
Tricor (FA-EXC)® (For Maryland Only)
Trentinoins
Tudorza
Tudorza (For Maryland Only)
Tykerb®
Tykerb® (For Maryland Only)
Tysabri®
Tysabri® (For Maryland Only)
Tyvaso®
Uptravi®
Valchlor®
Valchlor® (For Maryland Only)
Valcyte
Valcyte (For Maryland Only)
Valtrex (FA-EXC)®
Valtrex (FA-EXC)® (For Maryland Only)
Vantas®
Vascepa®
Velcade®
Velcade® (For Maryland Only)
Veletri®
Veltin®
Ventavis®
Ventonlin® HFA
Ventonlin® HFA (For Maryland Only)
Veramyst®
Veramyst® (For Maryland Only)
Viagra®
Viagra® (For Maryland Only)
Victrelis®
Vidaza®
Viekira Pak®
Viekira Pak® (For Maryland Only)
Vimizim®
Vimovo (FA-EXC)®
Vimovo (FA-EXC)® (For Maryland Only)
Visudyne®
Vogelxo®
Vogelxo® (For Maryland Only)
Votrient®
Votrient® (For Maryland Only)
VPRIV®
Wilate®
Wilate® (For Maryland Only)
Xalkori®
Xeljanz®
Xeljanz® (For Maryland Only)
Xeloda®
Xeloda® (For Maryland Only)
Xenazine®
Xeomin®
Xeomin® (For Maryland Only)
Xgeva®
Xgeva® (For Maryland Only)
Xifaxan®
Xolair®
Xolair® (For Maryland Only)
Xopenex® HFA
Xopenex® HFA (For Maryland Only)
Xtandi®
Xyntha®
Xyntha® (For Maryland Only)
Yervoy®
Zarxio®
Zavesca®
Zecuity®
Zelboraf®
Zemaira®
Zetonna®
Zetonna® (For Maryland Only)
Zoladex®
Zoledronic Acid®
Zomacton®
Zometa®
Zolinza®
Zorbtive®
Zubsolv®
Zubsolv® (For Maryland Only)
Zydelig®
Zydelig® (For Maryland Only)
Zykadia®
Zykadia® (For Maryland Only)
Zytiga®

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