Call us 1-800-868-5200 (TRS 711)
Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.

for:

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 Medicar e
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.

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Anonymous Compliance Hotline: Call our Compliance Hotline to report any concerns you may have regarding compliance, fraud, waste or abuse. You can call the Hotline 24 hours a day, seven days a week. All calls are anonymous and confidential.

Pharmacy prior authorizations

Prior authorization process

Patient-administered drugs (pharmacy benefit)

Electronic prior authorization tool (ePA)

Call or fax

Physician-administered drugs (medical benefit)

Patient-administered drugs (pharmacy benefit)

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

Commercial/Medicaid PA forms

Drug name

PA form

Medicare PA forms

Drug name

PA form

Physician-administered drugs (medical benefit)

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

Commercial, Medicaid, and Medicare PA forms and worksheets

Quick links

Helpful tools

Our plans and products

Employer group pages