PA Forms

File Description Date
Multiple Sclerosis Agents - Oral PA Form 470-5060 80.42 KB 2022/11/22
Antidepressant PA Form 470-5098 67.67 KB 2022/11/21
Dupilumab (Dupixent) PA Form 470-5497 83.57 KB 2022/11/21
Hepatitis C Treatments, Direct Acting Antivirals PA Form 470-5270 134.09 KB 2022/11/21
Vericiguat (Verquvo) PA Form 470-5685 79.25 KB 2022/11/21
Omalizumab (Xolair) PA Form 470-4279 84.52 KB 2022/11/21
CNS Stimulants and Atomoxetine PA Form 470-4116 87.85 KB 2022/11/21
Sedative/Hypnotic-Non_benzodiazepine PA Form 470-4328 72.74 KB 2022/11/21
Direct Oral Anticoagulants PA Form 470-5423 71.7 KB 2022/11/21
Topical Acne and Rosacea Products PA Form 470-5426 111.1 KB 2022/11/21
Acute Migraine Treatments PA Form 470-4113 72.28 KB 2022/11/21
Modified Formulations PA Form 470-4705 65.28 KB 2022/11/21
Maralixibat (Livmarli) PA Form 470-5731 75.48 KB 2022/11/21
Anti-Diabetic, Non-Insulin Agents PA Form 470-5259 78.54 KB 2022/11/21
Mavacamten (Camzyos) PA Form 470-5732 76.7 KB 2022/11/21
Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist, Oral PA Form 470-5578 73.13 KB 2022/11/21
Nebivolol (Bystolic) PA Form 470-5099 67.04 KB 2022/11/21
Alpelisib (Vijoice) PA Form 470-5730 64.04 KB 2022/11/21
Non-Parenteral Vasopressin Derivatives PA 470-4107 122.83 KB 2022/08/22
Nonsteroidal Anti-Inflammatory Drugs PA Form 470-4109 123.49 KB 2022/08/22
Non-Preferred Drug PA Form 470-4108 141.66 KB 2022/08/22
Crisaborole (Eucrisa) PA Form 470-5488 108.6 KB 2022/08/22
Testosterone Products PA Form 470-5188 123.48 KB 2022/08/22
Select Oncology Agents PA Form 470-5367 104.33 KB 2022/08/22
Tasimelteon (Hetlioz) PA Form 470-5296 108.04 KB 2022/08/22
Fentanyl, Short Acting Products PA Form 470-4092 148.35 KB 2022/08/22
Oral Immunotherapy PA Form 470-5295 110.78 KB 2022/08/22
Biologicals for Hidradenitis Suppurativa PA Form 470-5408 115.25 KB 2022/08/22
Antiemetic-5HT3 receptor Antogonists/Substance P Neurokinin Agents PA Form 470-4410 144.02 KB 2022/08/22
Granulocyte Colony Stimulating Factor PA Form 470-4099 106.64 KB 2022/08/22
Short Acting Opioids PA Form 470-4899 152.27 KB 2022/08/22
Ophthalmic Agents for Presbyopia PA Form 470-5718 130.32 KB 2022/08/22
Tralokinumab-ldrm (Adbry) PA Form 470-5719 177.44 KB 2022/08/22
Extended Release Formulation PA Form 470-4550 108.89 KB 2022/08/22
Benzodiazepines PA Form 470-4117 142.47 KB 2022/08/22
Baclofen PA Form 470-5694 105.69 KB 2022/08/22
Muscle Relaxants PA Form 470-4105 140.1 KB 2022/08/22
Pirfenidone (Esbriet) & Nintedanib (Ofev) PA Form 470-5346 132.55 KB 2022/08/22
Oral Constipation Agents PA Form 470-5174 119.44 KB 2022/08/22
Biologicals for Inflammatory Bowel Disease PA Form 470-4523 125.36 KB 2022/08/22
Janus Kinase Inhibitors PA Form 470-5175 124.19 KB 2022/08/22
Nocturnal Polyuria Treatments PA Form 470-5577 122.61 KB 2022/08/22
PCSK9 Inhibitors PA Form 470-5399 123.89 KB 2022/06/07
Pegcetacoplan (Empaveli) PA Form - 470-5715 110.12 KB 2022/06/07
Finerenone (Kerendia) PA Form - 470-5716 116.29 KB 2022/06/07
Odevixibat (Bylvay) PA Form - 470-5717 112.95 KB 2022/06/07
Erythropoiesis Stimulating Agents PA Form 470-4098 111.58 KB 2022/04/28
Naloxone Nasal Spray PA Form 470-5461 101.14 KB 2022/04/22
Select Non-Biologic Agents for Ulcerative Colitis PA Form 470-5683 100.63 KB 2022/04/22
Proton Pump Inhibitors PA Form 470-4112 125.13 KB 2022/04/22
Pulmonary Arterial Hypertension PA Form 470-4327 113.51 KB 2022/04/22
Triheptanoin (Dojolvi) PA Form 470-5693 108.91 KB 2022/04/22
Anti-Fungal PA Form 470-4094 107.81 KB 2022/04/22
Immunomodulators - Topical PA Form 470-5040 115.54 KB 2022/04/22
Growth Hormone PA Form 470-4100 152.7 KB 2022/04/22
Apremilast (Otezla) PA Form 470-5293 102.72 KB 2022/04/22
Repository Corticotropin Injection PA Form 470-5172 99.58 KB 2022/04/22
Selective Preventative Migraine Treatments PA Form 470-5554 119.75 KB 2022/04/22
Biologicals for Arthritis PA Form 470-4522 121.54 KB 2022/04/22
Deferasirox (Exjade) PA Form 470-5330 109.63 KB 2022/04/22
Viloxazine (Qelbree) PA Form 470-5684 102.12 KB 2021/11/19
Pavilizumab PA Form 470-4110 24.68 KB Palivizumab (Synagis®) approval periods will begin November 1, 2022 and will be considered through March 31, 2023, and as medically necessary based on RSV prevalence. A maximum of five doses will be allowed per member per RSV season. No allowances will be made for a sixth dose, regardless of start date. Requests may be submitted beginning October 10, 2022 for a therapy start date of November 1, 2022 2021/08/22
Binge Eating Disorder Agents PA Form 470-5336 112.95 KB 2021/08/05
Risdiplam (Evrysdi) PA Form 470-5671 118.6 KB 2021/08/05
Initial Days’ Supply Limit Override PA Form 470-5672 112.53 KB 2021/08/05
Select Anticonvulsants PA Form 470-5591 107.03 KB 2021/08/05
Isotretinoin (Oral) PA Form 470-4101 115.9 KB 2021/08/05
IL-5 Antagonists PA Form 470-5424 143.86 KB 2021/08/05
Vesicular Monoamine Transporter (VMAT) 2 Inhibitors PA Form 470-5534 128.38 KB 2021/08/05
Mannitol Inhalation Powder (Bronchitol) PA Form 470-5670 116.87 KB 2021/08/05
Satralizumab (Enspryng) PA Form 470-5652 133.04 KB 2021/05/20
Topical Antifungals for Onychomycosis PA Form 470-5368 102.83 KB 2021/04/16
Sapropterin (Kuvan) PA Form 470-5493 106.45 KB 2021/04/16
Sodium Oxybate Products PA Form 470-5016 125.02 KB 2021/04/16
Methotrexate Injection PA Form 470-5294 108.48 KB 2021/04/16
Eluxadoline (Viberzi) PA Form 470-5410 111.58 KB 2021/04/16
Cystic Fibrosis Agents, Oral PA Form 470-5627 118 KB 2020/11/20
Hematopoietics/Chronic ITP PA Form 470-4850 118.89 KB 2020/11/20
Peanut (Arachis Hypogaea) Allergen Powder-dnfp (Palforzia) PA Form 470-5637 124.13 KB 2020/11/20
Adenosine Triphosphate-Citrate Lyase Inhibitors PA Form 470-5636 125.92 KB 2020/11/20
Biologicals for Axial Spondyloarthritis PA Form 470-4521 131.26 KB 2020/11/20
Biologicals for Plaque Psoriasis PA Form 470-4524 117.68 KB 2020/11/20
Voxelotor (Oxbryta) PA Form 470-5628 113.59 KB 2020/09/14
Linezolid (Zyvox) PA Form 470-4275 121.62 KB 2020/08/24
Ivabradine (Corlanor) PA Form 470-5409 110.23 KB 2020/08/24
High Dose Opioids PA Form 470-5531 109.03 KB 2020/08/24
Lidocaine Patch PA Form 470-4898 103.65 KB 2020/08/24
Potassium Binders PA Form 470-5425 101.36 KB 2020/08/24
Dalfampridine (Ampyra) PA Form 470-5015 91.73 KB 2019/11/26
Febuxostat (Uloric) PA Form 470-4849 79.07 KB 2019/11/26
Antihistamines PA Form 470-4095 108.72 KB 2019/11/25
Aripiprazole Tablets with Sensor (Abilify MyCite) PA Form 470-5600 289.46 KB 2019/11/22
Ospemifene (Osphena) PA Form 470-5601 283.96 KB 2019/11/22
Lupron Depot - Adult PA Form 470-5435 28.97 KB 2019/08/26
Long-Acting Opioids PA form 470-4409 33.97 KB 2019/05/21
Miconazole-Zinc Oxide-White Petrolatum (Vusion) Ointment PA form 470-4655 24.6 KB 2019/04/30
Lupron Depot - Pediatric PA Form 470-5434 65.21 KB 2018/11/20
Letermovir (Prevymis) PA Form 470-5548 235.31 KB 2018/08/20
Age Edit Override- Codeine or Tramadol PA Form 470-5507 231.46 KB 2018/02/22
Selected Brand Name Drug PA Form 470-5039 & 470-4119 43.17 KB 2017/08/24
Deflazacort (Emflaza) PA Form 470-5489 25.98 KB 2017/08/23
GLP-1 Agonist/Basal Insulin Combinations PA Form 470-5490 24.77 KB 2017/08/23
New to Market Drugs PA Form 470-5492 23.02 KB 2017/08/23
Calcifediol (Rayaldee) PA Form 470-5487 24.57 KB 2017/08/23
Lesinurad (Zurampic) PA Form 470-5491 68.3 KB 2017/08/23
Duplicate Therapy Edit Override PA Form 470-5460 174.36 KB 2017/02/07
Rifaximin (Xifaxan) PA Form 470-5411 235.8 KB 2016/06/22
Cholic Acid (Cholbam) PA Form 470-5391 280.27 KB 2016/03/08
Alpha1-Proteinase Inhibitor Enzymes PA Form 470-5365 237 KB 2015/11/23
Topical Corticosteroids PA Form 470-5347 22.21 KB 2015/08/27
Dextromethorphan and Quinidine (Nuedexta™) PA Form 470-5084 30.17 KB 2015/06/04
Vorapaxar (Zontivity) PA Form 470-5331 23.4 KB 2015/04/17
Korlym (mifepristone) PA Form 470-5141 19.78 KB 2013/01/16
Ketorolac PA Form 470-4102 22.66 KB 2012/06/26
Roflumilast (Daliresp™) PA Form 470-5085 56.57 KB 2011/12/28
Fifteen Day Initial Prescription Supply Override PA Form 470-5038 14.22 KB 2011/07/11
Vitamins Minerals and Multiple Vitamins PA Form 470-4115 13.95 KB 2011/06/16
Quantity Limit Override Form 470-4556 107.21 KB 2010/10/06
Amylino Mimetic PA Form 470-4406 33.02 KB 2009/12/09
Narcotic Agonist Antagonist Nasal Spray PA Form 470-4106 33.79 KB 2009/07/27
Becaplermin (Regranex) PA Form 470-4276 24.3 KB 2008/09/05
Miscellaneous PA Form 470-4104 16.18 KB 2007/12/26