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The appropriate drug prior authorization (PA) form may be located by using the drug search function (at the top of this page) or by selecting the first letter of the drug to be requested (from the A to Z list displayed above). Once you find the requested drug, click on “PA” next to the drug name and the correct PA form will be highlighted in yellow on the page below.  If you already know which specific PA form you are looking for, you may select it from the following list by clicking on the link below. 


  • Androgen Therapy [10/31/16]  ( PDF )  |  TXT
  • Anti-Gout Agents [08/29/16]  ( PDF )  |  TXT
  • Anticoagulant and Antiplatelet [08/29/16]  ( PDF )  |  TXT
  • Anticonvulsant [10/31/16]  ( PDF )  |  TXT
  • Antidepressant [10/31/16]  ( PDF )  |  TXT
  • Antidiabetic Agents [10/31/16]  ( PDF )  |  TXT
  • Antiemetics [10/31/16]  ( PDF )  |  TXT
  • Antipsychotic [10/31/16]  ( PDF )  |  TXT
  • Antiretroviral Agents [10/31/16]  ( PDF )  |  TXT
  • Armodafinil and Modafinil [10/31/16]  ( PDF )  |  TXT
  • Asthma/Allergy Monoclonal Antibodies [10/31/16]  ( PDF )  |  TXT
  • Benign Prostatic Hyperplasia (BPH) Agents [08/29/16]  ( PDF )  |  TXT
  • Benzodiazepines and Other Antianxiety Agents [10/31/16]  ( PDF )  |  TXT
  • Brand-Name and Non-preferred Generic Drug [10/31/16]  ( PDF )  |  TXT
  • Cerebral Stimulant and ADHD Drugs [10/31/16]  ( PDF )  |  TXT
  • Constipation Agents [08/29/16]  ( PDF )  |  TXT
  • Corlanor and Entresto [10/31/16]  ( PDF )  |  TXT
  • Cystic Fibrosis (CFTR) Modulators [08/29/16]  ( PDF )  |  TXT
  • Dermatological Agents (Topical Chemotherapy and Genital Wart Therapy) [08/29/16]  ( PDF )  |  TXT
  • Dermatological Immune Suppressants [08/29/16]  ( PDF )  |  TXT
  • Erythropoietin [08/29/16]  ( PDF )  |  TXT
  • Gastrointestinal Agents - Antidiarrheals and Bowel Preparation Agents [08/29/16]  ( PDF )  |  TXT
  • General Drug [08/29/16]  ( PDF )  |  TXT
  • Glaucoma Agents [08/29/16]  ( PDF )  |  TXT
  • Gonadotropin Releasing Hormone [10/31/16]  ( PDF )  |  TXT
  • Growth Hormone [08/29/16]  ( PDF )  |  TXT
  • Headache Therapy (Butalbital Combination Agents and Migranal) [10/31/16]  ( PDF )  |  TXT
  • Headache Therapy (Triptan) [10/31/16]  ( PDF )  |  TXT
  • Hepatitis Antiviral Agents [10/31/16]  ( PDF )  |  TXT
  • Hereditary Angioedema Agents [08/29/16]  ( PDF )  |  TXT
  • Hyaluronan Injections [10/31/16]  ( PDF )  |  TXT
  • Hypnotic Agents [10/31/16]  ( PDF )  |  TXT
  • Immune Globulin [08/29/16]  ( PDF )  |  TXT
  • Immunomodulators [08/29/16]  ( PDF )  |  TXT
  • Increlex [08/29/16]  ( PDF )  |  TXT
  • Inhaled Respiratory Agents [08/29/16]  ( PDF )  |  TXT
  • Intranasal Corticosteroids [08/29/16]  ( PDF )  |  TXT
  • Intravenous Antibiotic [08/29/16]  ( PDF )  |  TXT
  • Lipid Lowering Agents [10/31/16]  ( PDF )  |  TXT
  • Multiple Sclerosis Agents [10/31/16]  ( PDF )  |  TXT
  • Nonsteroidal Anti-Inflammatory Drugs (NSAID) [08/29/16]  ( PDF )  |  TXT
  • Ophthalmic Anti-Allergy and Anti-Inflammatory Agents [08/29/16]  ( PDF )  |  TXT
  • Opioid Dependence and Reversal Agents [10/31/16]  ( PDF )  |  TXT
  • Opioids/Acetaminophen Analgesic [10/31/16]  ( PDF )  |  TXT
  • Oral Antibiotic [10/31/16]  ( PDF )  |  TXT
  • Oral Respiratory Agents [08/29/16]  ( PDF )  |  TXT
  • Oral/Injectable Antifungal [08/29/16]  ( PDF )  |  TXT
  • Oral/Intranasal Antihistamine Agents [08/29/16]  ( PDF )  |  TXT
  • Osteoporosis Agents [08/29/16]  ( PDF )  |  TXT
  • Otic Antibiotics [08/29/16]  ( PDF )  |  TXT
  • Pediatric Behavioral Health Medication Initiative [10/31/16]  ( PDF )  |  TXT
  • Pediculicides and Scabicides [08/29/16]  ( PDF )  |  TXT
  • Progesterone Agents [10/31/16]  ( PDF )  |  TXT
  • Prostate Cancer Agents [08/29/16]  ( PDF )  |  TXT
  • Proton Pump Inhibitor [10/31/16]  ( PDF )  |  TXT
  • Pulmonary Arterial Hypertension [08/29/16]  ( PDF )  |  TXT
  • Topical Anesthetics [10/31/16]  ( PDF )  |  TXT
  • Topical Antiviral [08/29/16]  ( PDF )  |  TXT
  • Topical Corticosteroids [08/29/16]  ( PDF )  |  TXT
  • Vitamin D Analogues [08/29/16]  ( PDF )  |  TXT