Pharmacy Prior Authorization Forms

Electronic Prior Authorization Link

Providers are able to complete prior authorizations online via the following link:

Electronic Prior Authorization Information
Texas Standardized Prior Authorization Form for Prescription Drugs
Texas Medicaid-CHIP Prior Authorization Criteria Guide

Pharmacy Prior Authorization Form Addendum Clinical Edit Details
  150mg Aliskiren-Containing Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  300mg Aliskiren-Containing Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  ADD/ADHD Clonidine ER Prior Authorization Form Addendum             Prior Authorization Criteria Logic
  ADD/ADHD ER Formulations Prior Authorization Form Addendum             Prior Authorization Criteria Logic
  ADD/ADHD IR Formulations Prior Authorization Form Addendum Prior Authorization Criteria Logic
  ADD/ADHD Non-stimulant Formulations Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Alinia Oral Suspension Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Alinia Tablets Prior Authorization Form Addendum             Prior Authorization Criteria Logic
  Allergen Extracts - Oralair Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Androgenic Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Antipsychotics Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Anxiolytics – Alprazolam Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Anxiolytics – Chlordiazepoxide, Meprobamate, Oxazepam Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Anxiolytics – Clonazepam, Diazepam Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Anxiolytics – Clorazepate Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Anxiolytics – Lorazepam Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Antiemetics Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Arikayce Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Binge Eating Disorder Agents Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Buprenorphine Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Buprenorphine-Naloxone Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Carisoprodol Containing Agents Prior Authorization Form Prior Authorization Criteria Logic
  Celebrex Prior Authorization Form Addendum Prior Authorization Criteria Logic
  CGRP Antagonists, Acute - Nurtec Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  CGRP Antagonists, Acute - Ubrelvy Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  CGRP Antagonists, Chronic Prior Authorization Form Addendum Prior Authorization Criteria Logic
  CNS Stimulants - Nuvigil Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  CNS Stimulants - Provigil Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  CNS Stimulants - Sunosi Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Colcrys Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Compounded Medications Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Contraceptives Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Copaxone Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cough and Cold Age 2-4 Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cough and Cold Age 2-6 Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cough and Cold Age 2-10 Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cough and Cold Age 2-12 Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cyclobenzaprine Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cymbalta Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cystic Fibrosis Agents - Orkambi Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Cystic Fibrosis Agents - Symdeko Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Cystic Fibrosis Agents - Trikafta Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Cytokine and CAM Antagonists - Actemra Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Cimzia Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Cosentyx Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Enbrel Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Humira Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Kevzara Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Ilaris Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Ilumya Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Kineret Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Olumiant Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Orencia Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Otezla Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Rinvoq Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Siliq Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Simponi Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists – Skyrizi Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Stelara Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Taltz Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists -Tremfya Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Cytokine and CAM Antagonists - Xeljanz Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Desmopressin Injectable Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Desmopressin Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Dextromethorphan Overutilization Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Diabetic Supplies (Medicaid and CHIP) Prior Authorization Form Addendum
  Diabetic Test Strips and Meters Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Diacomit Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Diclofenac 1.5% and 2% Topical Solution Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Diclofenac 3% Topical Gel Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Doxylamine Pyridoxine Prior Authorization Form Prior Authorization Criteria Logic
  DPP-4 Inhibitors Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Dupixent Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Early Refill Prior Authorization Form Addendum
  Emflaza Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes –Adagen/Revcovi Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes –Aldurazyme Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes –Ceprotin Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes –Elaprase Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes –Fabrazyme Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes – Lumizyme Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes – Naglazyme Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes – Nityr-Orfadin Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Enzymes - Vimizim Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Epidiolex Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Erythropoiesis-Stimulating Agents – Aranesp Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Erythropoiesis - Stimulating Agents - Epogen, Procrit or Retacrit Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Fentanyl – Actiq Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Fentanyl Agents -Abstral/Lazanda/Subsys Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Fentanyl - Duragesic Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Fentanyl - Fentora Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Forteo Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Gabapentin Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Gabapentin - Gralise Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Gabapentin - Horizant Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Gaucher's Disease Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  GI Motility – Amitiza Prior Authorization Form Addendum Prior Authorization Criteria Logic
  GI Motility – Linzess Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  GI Motility - Lotronex / Alosetron Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  GI Motility - Motegrity Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  GI Motility - Movantik / Symproic Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  GI Motility - Relistor Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  GI Motility - Trulance Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  GI Motility - Viberzi Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  GLP-1 Receptor Agonists Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Growth Hormone Agents -Excluding Serostim and Zorbtive Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Growth Hormone – Serostim Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Growth Hormone - Zorbtive Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Hereditary Angioedema (HAE) Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Hepatitis C Addendum - Texas Standard Prior Authorization Form - Effective March 1, 2021  
  Hepatitis C Agents First Fill/Refill Prior Authorization Form Addendum - Effective March 1, 2021  
  Hepatitis C Agents First Fill Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Hepatitis C Combined Addendum - Texas Standard Prior Authorization Form Prior Authorization Criteria Logic
  Hepatitis C Refill Request Prior Authorization Form Addendum Prior Authorization Criteria Logic
  H.P. Acthar Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Imiquimod – Aldara 5% Cream Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Imiquimod – Zyclara 3.75% Cream Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Increlex Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Inhaled Antibiotics Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Kalydeco Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Ketorolac Injectable/Nasal Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Ketorolac Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Keveyis Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Leukotriene Modifiers - Montelukast Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Leukotriene Modifiers - Zafirlukast Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Leukotriene Modifiers - Zileuton Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Lidocaine Patch Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Lovaza Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Lyrica Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Makena Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Monoclonal Antibody Agents for Asthma - Faserna Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  Monoclonal Antibody Agents for Asthma - Nucala Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  Non-Preferred Drugs Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Nuedexta Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Nuplazid Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Opiate/Benzodiazepine/Muscle Relaxant Combinations Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Opiate Overutilization Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Opioid Policy Prior Authorization Form Prior Authorization Criteria Logic
  Ophthalmic Immunomodulators Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  Oriahnn Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Orilissa Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Oxervate Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  Oxycontin High Dose Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Oxycontin Low Dose Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Palforzia Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  PCSK9 Inhibitors - Praluent Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  PCSK9 Inhibitors - Repatha Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  PDE5 Inhibitors - Sildenafil / Tadalafil Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Alzheimer's Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Analgesics, Narcotic-Long Acting Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Analgesics, Narcotic-Short Acting Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Androgenic Agents, Topical Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Angiotensin Modulator Combinations Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Angiotensin Modulators Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Anti-Allergens, Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antibiotics, GI (excluding Xifaxan 550mg) Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antibiotics Topical Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antibiotics, Vaginal Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Anticoagulants Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antidepressants Other Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antidepressants SSRI Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antidepressants Tricyclic Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antiemetic-Antivertigo Agents Prior Authorization Form Prior Authorization Criteria Logic
  PDL Antifungals, Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antifungals, Topical Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antihistamines, First Generation Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antihistamines, Minimally Sedating Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antihypertensives, Sympatholytics Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antihyperuricemics Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antimigraine Agents, Other Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antimigraine Agents, Triptans Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antiparasitics, Topical Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antiparkinson's Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antivirals, Oral/Nasal Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Antivirals, Topical Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Beta Blockers Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Bile Salts Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Bladder Relaxant Preparations Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Bone Resorption Suppression and Related Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL BPH Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Bronchodilators, Beta Agonists Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Calcium Channel Blockers Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Cephalosporins and Related Antibiotics (Oral) Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Colony Stimulating Factors Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL COPD Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Epinephrine, Self-Injected Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Fluoroquinolones, Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Glucagon Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  PDL Glucocorticoids, Inhaled Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Glucocorticoids, Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL H.Pylori Treatment Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Hypoglycemics, Incretin Mimetics/Enhancers Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Hypoglycemics, Insulin Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Hypoglycemics, Meglitinides Prior Authorization Form Addendum             Prior Authorization Criteria Logic
  PDL Hypoglycemics, Metformin Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Hypoglycemics, TZD Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Immune Globulins Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Immunosuppressives Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Intranasal Rhinitis Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Iron, Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Lincosamides/Oxazolidinones/Streptogramins Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Lipotropics, Other Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Lipotropics Statins Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Macrolides (Oral) Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Movement Disorders Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Neuropathic Pain Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL NSAIDS Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Ophthalmics, Allergic Conjunctivitis Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Ophthalmics Anti-Inflammatory_ Immunomodulators Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Ophthalmics, Antibiotic Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Ophthalmics, Antibiotic-Steroid Combinations Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Ophthalmics, Glaucoma Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Opiate Dependence Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Otic Antibiotics Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Otic AntiInfectives/Anesthetics Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Pancreatic Enzymes Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Pediatric Vitamin Preparations Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Penicillins Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Platelet Aggregation Inhibitors Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Progestational Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Progestins for Cachexia Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Proton Pump Inhibitors Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  PDL Skeletal Muscle Relaxants Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Smoking Cessation Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Steroids, Topical Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Tetracyclines Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Thrombopoiesis Stimulating Proteins Prior Authorization Form Addendum Prior Authorization Criteria Logic
  PDL Ulcerative Colitis Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Phosphate Binders Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Prenatal Vitamins Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Promethazine Containing Products Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Propylthiouracil Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Proton Pump Inhibitors Oral Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Pulmonary Hypertension – Injectable Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Pulmonary Hypertension – Oral/Inhaled Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Ranexa Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Retrospective DUR Prior Authorization Form Addendum 
  Savella Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Sedative/Hypnotics -Adults Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Sedative/Hypnotics-Butabarbital Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Sedative/Hypnotics-Flurazepam Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Sedative/Hypnotics- Ramelteon & Tasimelteon Prior Authorization Form Addendum Prior Authorization Criteria Logic
  SGLT2 Inhibitors - Combination Prior Authorization Form Addendum Prior Authorization Criteria Logic
  SGLT2 Inhibitors - Single Entity Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Sickle Cell Disease Agents - Oxbryta Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Symlin Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Synagis Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Thiazolidinediones Rosiglitazone Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Thiazolidinediones Pioglitazone Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Topical Acne Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Topical Immunomodulators-Elidel and Protopic 0.03% Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Topical Immunomodulators Eucrisa Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Topical Immunomodulators - Protopic 0.1% Ointment Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Topical Retinoids Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Transthyretin Agents - Tegsedi Prior Authorization Form Addendum Prior Authorization Criteria Logic 
  Transthyretin Agents - Vyndamax / Vyndaqel Prior Authorization Form Addendum   Prior Authorization Criteria Logic  
  Urea Cycle Disorder Agents Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Vitamins/Minerals Prior Authorization Form Addendum Prior Authorization Criteria Logic
  VMAT Inhibitors - Austedo Prior Authorization Form Addendum Prior Authorization Criteria Logic
  VMAT Inhibitors - Ingrezza Prior Authorization Form Addendum Prior Authorization Criteria Logic
  VMAT Inhibitors - Xenazine Prior Authorization Form Addendum             Prior Authorization Criteria Logic
  Wakix Prior Authorization Form Addendum  Prior Authorization Criteria Logic 
  Xifaxan 200mg Prior Authorization Form Addendum                         Prior Authorization Criteria Logic
  Xifaxan 550mg Prior Authorization Form Addendum             Prior Authorization Criteria Logic
  Xyrem/Xywav Prior Authorization Form Addendum Prior Authorization Criteria Logic
  Zelboraf Prior Authorization Form Addendum                         Prior Authorization Criteria Logic
           
     
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