Prior Authorization Forms

Prior Authorization (approval in advance) is required for many procedures, services or supplies, including transportation.  Click here for information on obtaining an Emergency PA for medications.  Below are the forms used for Prior Authorization.

PA Forms
Form 342 Prior Review and Authorization Request Note: a completed form is required.    
Form 384 Attachment to Form 342 for Wheelchair Evaluation Request    ***Please verify that all text typed into the form is present, once the form is printed. If not, please continue text on page 7, in "Comments" section.
Form 471 Prior Authorization Change Request (NOT to be used for Pharmacy prior authorizations) - 3/20/24
PHY-96-11 Cochlear Implant Request
Form 343 Dental PA Form
Form 386 Wheelchair Modification/Repair Form    ***This form is mandatory for prior authorizations.
Form 360 Oxygen Therapy Request
Form 480 Augmentative Communication Device (ACD) Evaluation Report Form
Form 480 Instructions for ACD Evaluation Report
Web Portal Radiology (CTA Scans, CT Scans, PET Scans, MRAs, MRIs)
Web Portal Cardiology Services
ABA Therapy ABA Therapy Behavior Assessment Form - Form must be completed and submitted as supporting documentation for an ABA therapy PA request - Fillable - Revised 6/20/19
ABA Therapy Instructions ABA Therapy Prior Authorization Instructions for Providers
ABA Therapy Tips ABA Therapy Provider Tip Sheet
Rehabilitative Services  Rehabilitative Services Prior Review and Authorization Request - Form must be completed and submitted for a PA request - Fillable - 11/6/17
Rehabilitative Services Rehabilitative Services Prior Review and Authorization Request - Form must be completed and submitted for a PA request - Printable - 11/6/17
Pharmacy Prior Authorization Forms   
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 391 Opioid Dependence Treatment Agreement and Patient Consent Form - 10/1/23
Form 390 Miscellaneous PA Request Form (EPSDT/Medical Necessity, Compounding) - 10/1/24
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
Form 410-B Child Growth Hormone/Turner, Prader-Wili, or Noonan Syndrome PA Request Form
Form 410-C Child Growth Failure/Mecasermin PA Request Form
Form 410-D Child Growth Hormone /Chronic Renal Insufficiency PA Request Form
Form 411 Adult Growth Failure PA Request Form
Form 366 Growth Failure for AIDS Wasting Request PA Request Form
Form 373 DMARDS/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

 

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