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.
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 |