PA Forms

File Description Date
Anti-Diabetic, Non-Insulin Agents PA Form 470-5259 123.22 KB 2019/12/02
Modified Formulations PA Form 470-4705 97.11 KB 2019/12/02
Insulin, Pre-Filled Pens PA Form 470-4111 123.26 KB 2019/12/02
Erythropoiesis Stimulating Agents PA Form 470-4098 96.37 KB 2019/11/26
Febuxostat (Uloric) PA Form 470-4849 79.07 KB 2019/11/26
Pulmonary Arterial Hypertension PA Form 470-4327 103.38 KB 2019/11/26
Vesicular Monoamine Transporter (VMAT) 2 Inhibitors PA Form 470-5534 415.56 KB 2019/11/26
Sedative/Hypnotic-Non_benzodiazepine PA Form 470-4328 119.62 KB 2019/11/26
CGRP Inhibitors PA Form 470-5554 396.38 KB 2019/11/26
Granulocyte Colony Stimulating Factor PA Form 470-4099 91.5 KB 2019/11/26
Immunomodulators - Topical PA Form 470-5040 105.69 KB 2019/11/26
Serotonin 5-HT1-receptor Agonists PA Form 470-4113 104.42 KB 2019/11/26
Short Acting Opioids PA Form 470-4899 187.96 KB 2019/11/26
Nonsteroidal Anti-Inflammatory Drugs PA Form 470-4109 107.79 KB 2019/11/26
Lidocaine Patch (Lidoderm) PA Form 470-4898 93.82 KB 2019/11/26
Biologicals for Arthritis PA Form 470-4522 145.73 KB 2019/11/26
Muscle Relaxants PA Form 470-4105 124.14 KB 2019/11/26
Mepolizumab (Nucala) PA Form 470-5424 420.25 KB 2019/11/26
Chronic Pain Syndromes PA Form 470-4551 457.25 KB 2019/11/26
Eluxadoline (Viberzi) PA Form 470-5410 303.21 KB 2019/11/26
Dalfampridine (Ampyra) PA Form 470-5015 91.73 KB 2019/11/26
CNS Stimulants and Atomoxetine PA Form 470-4116 136.11 KB 2019/11/26
Non-Parenteral Vasopressin Derivatives PA 470-4107 106.99 KB 2019/11/26
Oral Constipation Agents PA Form 470-5174 317.62 KB 2019/11/26
Buprenophine/Naloxone PA Form 470-5142 303.07 KB 2019/11/26
Janus Kinase Inhibitors PA Form 470-5175 224.76 KB 2019/11/26
Novel Oral Anticoagulants PA Form 470-5423 378.85 KB 2019/11/25
Topical Acne and Rosacea Products PA Form 470-5426 299.6 KB 2019/11/25
Testosterone Products PA Form 470-5188 328.78 KB 2019/11/25
Multiple Sclerosis Agents - Oral PA Form 470-5060 159.56 KB 2019/11/25
Antihistamines PA Form 470-4095 108.72 KB 2019/11/25
PCSK9 Inhibitors PA Form 470-5399 449.71 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
Deferasirox (Exjade) PA Form 470-5330 63.61 KB 2019/08/26
Lupron Depot - Adult PA Form 470-5435 28.97 KB 2019/08/26
Benzodiazepines PA Form 470-4117 34.76 KB 2019/08/26
Hematopoietics/Chronic ITP PA Form 470-4850 67.5 KB 2019/08/26
Dupilumab (Dupixent) PA Form 470-5497 108.37 KB 2019/08/26
Cannabidiol (Epidiolex) PA Form 470-5591 148.47 KB 2019/08/26
Growth Hormone PA Form 470-4100 86.74 KB 2019/08/26
Biologicals for Plaque Psoriasis PA Form 470-4524 27.54 KB 2019/08/26
Pavilizumab PA Form 470-4110 24.68 KB Palivizumab (Synagis®) approval periods will begin November 1, 2019 and will be considered through March 31, 2020. A maximum of five doses will be allowed per member during this time period. No allowances will be made for a sixth dose. Requests may be submitted beginning October 14, 2019 for a therapy start date of November 1, 2019. 2019/07/25
Hepatitis C Treatments PA Form 470-5270 154.5 KB 2019/05/21
Long-Acting Opioids PA form 470-4409 33.97 KB 2019/05/21
Sodium Oxybate (Xyrem) PA Form 470-5016 33.63 KB 2019/05/21
Anti-Fungal PA Form 470-4094 23.52 KB 2019/04/30
Elagolix (Orilissa) PA Form 470-5578 30.92 KB 2019/04/30
Lumacaftor/Ivacaftor (Orkambi) PA Form 470-5366 23.15 KB 2019/04/30
Nocturnal Polyuria Treatments PA Form 470-5577 36.37 KB 2019/04/30
Biologicals for Ankylosing Spondylitis PA Form 470-4521 29.06 KB 2019/04/30
Miconazole-Zinc Oxide-White Petrolatum (Vusion) Ointment PA form 470-4655 24.6 KB 2019/04/30
Biologicals for Inflammatory Bowel Disease PA Form 470-4523 28.62 KB 2019/04/30
Kalydeco (ivacaftor) PA Form 470-5117 29.77 KB 2019/04/30
High Dose Opioids PA Form 470-5531 117.83 KB 2019/04/01
Potassium Binders PA Form 470-5425 25.17 KB 2018/11/20
Lupron Depot - Pediatric PA Form 470-5434 65.21 KB 2018/11/20
Valsartan/Sacubitril (Entresto) PA Form 470-5398 65.87 KB 2018/11/20
Extended Release Formulation PA Form 470-4550 22.85 KB 2018/11/20
Letermovir (Prevymis) PA Form 470-5548 235.31 KB 2018/08/20
Tezacaftor/Ivacaftor (Symdeko) PA Form 470-5549 199.65 KB 2018/08/20
Methotrexate Injection PA Form 470-5294 28.92 KB 2018/08/20
Linezolid (Zyvox) PA Form 470-4275 31.85 KB 2018/08/20
Apremilast (Otezla) PA Form 470-5293 61.86 KB 2018/08/20
Alpha 2 Agonist, Extended Release PA Form 470-5018 26.39 KB 2018/04/23
Age Edit Override- Codeine or Tramadol PA Form 470-5507 231.46 KB 2018/02/22
Antidepressant PA Form 470-5098 26.88 KB 2017/11/20
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
Crisaborole (Eucrisa) PA Form 470-5488 26.29 KB 2017/08/23
GLP-1 Agonist/Basal Insulin Combinations PA Form 470-5490 24.77 KB 2017/08/23
Sapropterin (Kuvan) PA Form 470-5493 64.98 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
Antiemetic-5HT3 receptor Antogonists/Substance P Neurokinin Agents PA Form 470-4410 27.72 KB 2017/04/25
Fentanyl, Short Acting Products PA Form 470-4092 28.87 KB 2017/04/18
Narcan (Naloxone) Nasal Spray PA Form 470-5461 174.93 KB 2017/02/20
Duplicate Therapy Edit Override PA Form 470-5460 174.36 KB 2017/02/07
Concurrent IM/PO Antipsychotic PA Form 470-4594 23.68 KB 2017/02/07
Rifaximin (Xifaxan) PA Form 470-5411 235.8 KB 2016/06/22
Biologicals for Hidradenitis Suppurativa PA Form 470-5408 179.68 KB 2016/06/22
Ivabradine (Corlanor) PA Form 470-5409 238.47 KB 2016/06/22
Binge Eating Disorder Agents PA Form 470-5336 238.27 KB 2016/03/08
Cholic Acid (Cholbam) PA Form 470-5391 280.27 KB 2016/03/08
Isotretinoin (Oral) PA Form 470-4101 31.76 KB 2015/11/24
Alpha1-Proteinase Inhibitor Enzymes PA Form 470-5365 237 KB 2015/11/23
Select Oncology Agents PA Form 470-5367 182.43 KB 2015/11/23
Topical Antifungals for Onychomycosis PA Form 470-5368 177.29 KB 2015/11/23
Idiopathic Pulmonary Fibrosis PA Form 470-5346 70.34 KB 2015/08/27
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
Oral Immunotherapy PA Form 470-5295 28.8 KB 2015/04/21
Vorapaxar (Zontivity) PA Form 470-5331 23.4 KB 2015/04/17
Tasimelteon (Hetlioz) PA Form 470-5296 22.64 KB 2014/11/24
Proton Pump Inhibitors PA Form 470-4112 27.56 KB 2014/04/23
Repository Corticotropin Injection PA Form 470-5172 19.2 KB 2013/08/26
Korlym (mifepristone) PA Form 470-5141 19.78 KB 2013/01/16
Ketorolac PA Form 470-4102 22.66 KB 2012/06/26
Nebivolol (Bystolic) PA Form 470-5099 17.28 KB 2012/03/13
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
Non-Preferred Drug PA Form 470-4108 13.86 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