Prior Authorization Forms

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Prior Authorization Forms

Actiq-Fentora
PDF | 29 KB
Adult ADHD Long-acting Stimulants
PDF | 30 KB
Amitiza
PDF | 29 KB
Antifungal-Sporanox
PDF | 37 KB
ARBs
PDF | 37 KB
Byetta-Victoza
PDF | 31 KB
Cialis-Levitra-Viagra
PDF | 37 KB
Cymbalta
PDF | 30 KB
Emsam

PDF | 38 KB

Fibromyalgia
PDF | 35 KB
Gleevec
PDF | 42 KB
Insulin Pen
PDF | 34 KB
Kuvan
PDF | 64 KB

Lovaza


PDF | 37 KB
Lyrica
PDF | 36 KB
Nexavar
PDF | 69 KB
Non-Formulary General
PDF | 55 KB
Onychomycosis
PDF | 37 KB
Opana-Nucynta
PDF | 37 KB
Oxycontin
PDF | 29 KB
PPI High Dose
PDF | 33 KB
Prior Auth General
PDF | 27 KB
Promacta
PDF | 30 KB
Provigil-Nuvigil Narcolepsy
PDF | 31 KB
Provigil-Nuvigil OSA
PDF | 30 KB
Quantity Override
PDF | 55 KB
Relistor
PDF | 35 KB
Revatio
PDF | 68 KB
Revlimid
PDF | 40 KB
Singulair
PDF | 30 KB
Sprycel
PDF | 68 KB
Suboxone
PDF | 37 KB
Sutent
PDF | 68 KB
Symlin
PDF | 33 KB
Tarceva
PDF | 35 KB
Tekturna-Valturna
PDF | 39 KB
Temodar
PDF | 35 KB
Testosterone
PDF | 42 KB
Thalomid
PDF | 36 KB
Tracleer
PDF | 36 KB
Ventavis
PDF | 39 KB
Vivaglobin
PDF | 66 KB
Xeloda
PDF | 69 KB
Xenazine
PDF | 36 KB
Xyrem
PDF | 64 KB
Zavesca
PDF | 34 KB

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