PA Review Form and Provider Certification Form
PA Review Form
To initiate a prior authorization request of your prescription drugs, your physician may fill out a prior authorization review form and fax it directly to the Pharmacy Benefit Manager at the number
listed on the form. Please click on the link below for the prescription drug prior authorization review form for the drug you would like to initiate a review on:
Alpha Interferons (PDF, 1.13 MB)
Alferon N (PDF, 234 KB)
Anti-fungal Agents
- Lamisil and Sporanoxl (PDF, 236 KB)
- Noxafil (PDF, 290 KB)
- Vfend (PDF, 290 KB)
Anti-narcoleptic Agents (Provigil) (PDF, 1.5 MB)
Appetite Suppressant Agents Fax Form (PDF, 1.15 MB)
Bisphosphonates
- Actonel and Actonel with Calcium (PDF, 293 KB)
Certolizumab (Cimzia) (PDF, 296 KB)
Clostridium Botulinum Neurotoxins (Botox, Myobloc) (PDF, 235 KB)
COX2 Inhibitors (Celebrex) (PDF, 230 KB)
Fentanyl (Actiq and Fentora)(PDF, 296 KB)
Fertility Agents (PDF, 1.2 MB)
Growth Stimulating Drugs (PDF, 798 KB)
Immunomodulators
- Revlimid (PDF, 1.19 MB)
- Thalomid (PDF, 1.19 MB)
- Thalomid Renewal (PDF, 1.19 MB)
Migraine Agents (PDF, 475 KB)
Multiple Sclerosis Agents
- Avenex, Rebif and Betaseron (PDF, 1.19 MB)
- Copaxone (PDF, 1.19 MB)
- Copaxone Renewal (PDF, 1.19 MB)
- Tysabri (PDF, 1.19 MB)
Non-Sedating Antihistamines (PDF, 233 KB)
Omalizumab (Xolair) (PDF, 1.18 MB)
Proton Pump Inhibitors
- Aciphex, Prevacid and Protonix (PDF, 1.19 MB)
- Other Proton Pump Inhibitors (PDF, 1.15 MB)
Psoriasis Treatment Agents (PDF, 1.2 MB)
Rheumatoid Arthritis Agents (PDF, 3.97 MB)
Sedative Hypnotic Agents (PDF, 237 KB)
Selective Serotonin Reuptake Inhibitors (SSRIs) (PDF, 289 KB)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) (Effexor XR, Pristiq) (PDF, 140 KB)
Sildenafil (Revatio) (PDF, 1.13 MB)
Provider Certification Form
NRT Provider Certification Form (PDF, 22 KB)
