PA Forms

File Description Date
Insulin, Pre-Filled Pens PA Form 470-4111 248.8 KB 2017/05/08
Antiemetic-5HT3 receptor Antogonists/Substance P Neurokinin Agents PA Form 470-4410 27.72 KB 2017/04/25
Anti-Fungal PA Form 470-4094 23.77 KB 2017/04/25
Anti-Diabetic, Non-Insulin Agents PA Form 470-5259 26.22 KB 2017/04/25
Hepatitis C Treatments PA Form 470-5270 167.49 KB 2017/04/25
Angiotension Receptor Blocker Before ACE Inhibitor PA Form 470-4593 24.63 KB 2017/04/25
Novel Oral Anticoagulants PA Form 470-5423 101.27 KB 2017/04/25
Modified Formulations PA Form 470-4705 24.55 KB 2017/04/25
Lumacaftor/Ivacaftor (Orkambi) PA Form 470-5366 182.06 KB 2017/04/25
Eteplirsen (Exondys 51) PA Form 470-5476 236.33 KB 2017/04/25
Daclizumab (Zinbryta) PA Form 470-5462 184.18 KB 2017/04/18
Fentanyl, Short Acting Products PA Form 470-4092 188.79 KB 2017/04/18
Hepatitis C Post Treatment Information Sustained Virologic Response (SVR) Reporting PA Form 470-5463 237.5 KB 2017/02/24
Multiple Sclerosis Agents - Oral PA Form 470-5060 266.76 KB 2017/02/20
Narcan (Naloxone) Nasal Spray PA Form 470-5461 174.93 KB 2017/02/20
Alpha 2 Agonist, Extended Release PA Form 470-5018 187.72 KB 2017/02/20
Omalizumab (Xolair) PA Form 470-4279 245.81 KB 2017/02/20
Oral Constipating Agents PA Form 470-5174 209.94 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 174.21 KB 2017/02/07
CNS Stimulants and Atomoxetine PA Form 470-4116 259.89 KB 2017/01/09
Buprenophine/Naloxone PA Form 470-5142 198.32 KB 2016/11/21
Testosterone Products PA Form 470-5188 220.89 KB 2016/11/21
Biologicals for Ankylosing Spondylitis PA Form 470-4521 193.24 KB 2016/11/21
Biologicals for Arthritis PA Form 470-4522 197.46 KB 2016/11/21
Serotonin 5-HT1-receptor Agonists PA Form 470-4113 181 KB 2016/11/21
Topical Acne and Rosacea Products PA Form 470-5426 195.56 KB 2016/11/21
Short Acting Opioids PA Form 470-4899 243.69 KB 2016/11/21
Lupron Depot - Adult PA Form 470-5435 248.74 KB 2016/11/21
Biologicals for Plaque Psoriasis PA Form 470-4524 190.67 KB 2016/11/21
Lupron Depot - Pediatric PA Form 470-5434 244.15 KB 2016/11/21
Colchicine PA Form 470-5059 186.91 KB 2016/11/21
Pulmonary Arterial Hypertension PA Form 470-4327 30.04 KB 2016/08/23
Janus Kinase Inhibitors PA Form 470-5175 28.19 KB 2016/08/19
Deferasirox (Exjade) PA Form 470-5330 64.2 KB 2016/08/19
Mepolizumab (Nucala) PA Form 470-5424 67.76 KB 2016/08/19
Potassium Binders PA Form 470-5425 25.16 KB 2016/08/19
Extended Release Formulation PA Form 470-4550 22.93 KB 2016/08/19
Smoking Cessation Therapy - Oral PA Form 470-4517 248.28 KB 2016/08/02
Nicotine Replacement Therapy 470-4421 193.75 KB 2016/08/02
Biologicals for Hidradenitis Suppurativa PA Form 470-5408 179.68 KB 2016/06/22
Eluxadoline (Viberzi) PA Form 470-5410 198.01 KB 2016/06/22
Ivabradine (Corlanor) PA Form 470-5409 238.47 KB 2016/06/22
Rifaximin (Xifaxan) PA Form 470-5411 235.8 KB 2016/06/22
Long-Acting Opioids PA form 470-4409 240.23 KB 2016/06/22
Sodium Oxybate (Xyrem) PA Form 470-5016 249.1 KB 2016/04/26
Non-Parenteral Vasopressin Derivatives PA 470-4107 257.36 KB 2016/04/26
Non-Steroidal Anti-Inflammatory Drugs PA Form 470-4109 196.36 KB 2016/04/26
PCSK9 Inhibitors PA Form 470-5399 294.12 KB 2016/04/25
Valsartan/Sacubitril (Entresto) PA Form 470-5398 204.66 KB 2016/04/25
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
Granulocyte Colony Stimulating Factor PA Form 470-4099 23.67 KB 2015/11/24
Biologicals for Inflammatory Bowel Disease PA Form 470-4523 28.96 KB 2015/11/24
Linezolid (Zyvox) PA Form 470-4275 31.85 KB 2015/11/24
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
Pavilizumab PA Form 470-4110 24.68 KB Palivizumab (Synagis®) approval periods will begin November 2, 2015 and will be considered through March 31, 2016. 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 12, 2015 for a therapy start date of November 2, 2015. 2015/09/17
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
Immunomodulators - Topical PA Form 470-5040 52.86 KB 2015/08/26
Kalydeco (ivacaftor) PA Form 470-5117 32.52 KB 2015/08/26
Sedative/Hypnotic-Non_benzodiazepine PA Form 470-4328 28.77 KB 2015/06/04
Dextromethorphan and Quinidine (Nuedexta™) PA Form 470-5084 30.17 KB 2015/06/04
Chronic Pain Syndromes PA Form 470-4551 31.58 KB 2015/06/04
Apremilast (Otezla) PA Form 470-5293 62.27 KB 2015/04/21
Benzodiazepines PA Form 470-4117 32.44 KB 2015/04/21
Oral Immunotherapy PA Form 470-5295 28.8 KB 2015/04/21
Methotrexate Injection PA Form 470-5294 28.97 KB 2015/04/21
Thrombopoietin Receptor Agonists PA Form 470-4850 73.62 KB 2015/04/21
Vorapaxar (Zontivity) PA Form 470-5331 23.4 KB 2015/04/17
Growth Hormone PA Form 470-4100 205.4 KB 2015/03/08
Tasimelteon (Hetlioz) PA Form 470-5296 22.64 KB 2014/11/24
Antidepressant PA Form 470-5098 23.17 KB 2014/06/12
Proton Pump Inhibitors PA Form 470-4112 27.56 KB 2014/04/23
Antihistamines PA Form 470-4095 21.13 KB 2014/04/23
Lidocaine Patch (Lidoderm) PA Form 470-4898 22.11 KB 2014/04/23
Repository Corticotropin Injection PA Form 470-5172 19.2 KB 2013/08/26
Selected Brand Name Drug PA Form 470-5039 & 470-4119 145.72 KB 2013/03/18
Erythropoesis Stimulating Agents PA Form 470-4098 72.46 KB 2013/03/18
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
Muscle Relaxants PA Form 470-4105 19.17 KB 2011/09/12
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
Dalfampridine (Ampyra) PA Form 470-5015 17.63 KB 2011/02/11
Quantity Limit Override Form 470-4556 96.04 KB 2010/10/06
Amylino Mimetic PA Form 470-4406 33.02 KB 2009/12/09
Febuxostat (Uloric) PA Form 470-4849 34.86 KB 2009/10/02
Narcotic Agonist Antagonist Nasal Spray PA Form 470-4106 33.79 KB 2009/07/27
Vusion Ointment PA form 470-4655 27.19 KB 2008/12/11
Becaplermin (Regranex) PA Form 470-4276 47.11 KB 2008/09/05
Miscellaneous PA Form 470-4104 29.29 KB 2007/12/26