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| Form 369 |
Pharmacy Prior Authorization Request - Effective 10/1/24 |
| Form 369/389 Instructions |
Pharmacy Prior Authorization - Criteria - Effective 10/1/24 |
Form 369/389
Instructions |
Pharmacy Prior Authorization - Criteria - Effective 1/2/25 |
| Online PA Form |
For use by Health Professionals Only |
| Form 389 |
Opioid Dependence Treatment PA Form – 1/1/25 |
| Form 409 |
Pharmacy Override - 10/1/24 |
| Form 412 |
Short Acting Opiate Naïve Days’ Supply Limit Override - 10/1/24 |
| Form 409/412 Instructions |
Pharmacy Override External Criteria - Effective 1/1/24 |
| Form 413 |
Morphine Milligram Equivalents (MME) Cumulative Daily Override Form - 10/1/24 |
| Form 413 Instructions |
MME Cumulative Daily Override External Criteria - Effective 7/20/23 |
| Form 390 |
Miscellaneous PA Request Form (EPSDT/Medical Necessity, Compounding) - 10/1/24 |
| Form 391 |
Opioid Dependence Treatment Agreement and Patient Consent Form - 10/1/23 |
| Form 351 |
Synagis® PA Request - Effective 10/1/24 |
| Form 351 Criteria |
Synagis® PA Criteria - Effective 10/1/24 |
| Form 351 - Instructions |
Synagis® PA Instructions Worksheet - Effective 10/1/24 |
| Form 351 ICD-10 Worksheet |
Synagis® PA Worksheet - Appendix A - ICD-10 - Effective 10/1/24 |
| Form 470 |
Smoking Cessation Prior Authorization Request Form |
| Form 410-A |
Child Growth Hormone Deficiency PA Request Form - 10/8/24 |
| Form 410-B |
Child Growth Hormone/Turner, Prader-Wili, or Noonan Syndrome PA Request Form - 10/8/24 |
| Form 410-C |
Child Growth Failure/Mecasermin PA Request Form - 10/8/24 |
| Form 410-D |
Child Growth Hormone /Chronic Renal Insufficiency PA Request Form- 10/8/24 |
| Form 411 |
Adult Growth Failure PA Request Form - 10/8/24 |
| Form 366 |
Growth Failure for AIDS Wasting Request PA Request Form - 10/8/24 |
| Form 373 |
DMARD/Biological Injectables PA Request Form - 10/1/24 |
| Form 373 - Instructions |
Form 373 Instructions - DMARDS/Biological Injectables - 10/1/24 |
| Form 415 |
Hepatitis C Antiviral Agents PA Form - 10/1/24 |
| Form 415 - Instructions |
Form 415 Instructions - Hepatitis C Antiviral Agents External Criteria - Effective 2/28/24 |
| Form 392 |
Patient Consent Form for Hepatitis C Agents - 10/1/22 |
| Criteria |
Antipsychotic Prior Authorization Criteria |
| Attachment A |
Antipsychotic Agents - Attachment A - 6/1/24 |
| Attachment B |
Antipsychotic Agents - Attachment B |
| Attachment C |
Antipsychotic Agents - Attachment C |
| Form |
Psychiatrist Specialty Notification for Prior Authorization of all Antipsychotic Drugs - 10/30/24 |
| Form 384 |
Wheelchair Seating Evaluation Form |