Prescription Drug Forms

Prior Authorization *

5 HI1 Agonist Post Limit
Abraxane®
Abstral®
Abraxane® (For Maryland Only)
Accu-Chek Aviva Plus Test Strips
Accu-Chek Strips and Kits 4
Accu-Chek Strips and Kits 4 (For Maryland Only)
Actemra® (Medical)
Actemra® (Medical) (For Maryland Only) 
Actemra® (Formulary 1 and 2)
Actemra® (For Maryland Only) (Formulary 1 and 2)
Actemra® (Formulary 3)
Actemra® (for Maryland only) (Formulary 3)
Acthar®
Acthar® (For Maryland Only)
Actimmune®
Actimmune® (For Maryland Only)
Actiq®
Adagen®
Adcetris
Adcirca®
Adempas®
Afstyla®
Advate®
Advate® (For Maryland Only)
Afinitor®
Afinitor® (For Maryland Only)
Aldurazyme®
Alecensa®
Alimta®
Alimta® (For Maryland Only)
Alphanate®
Alphanate® (For Maryland Only)
Alphanine SD®
Alprolix®
Alsuma®
Alunbrig®
Alunbrig® (for Maryland only)
Amerge®
Ampyra®
Ampyra® (For Maryland Only)
Angiotensin II Receptor Antagonists Combo FA-EXC®
Angiotensin II Receptor Antagonists Combo FA-EXC® (For Maryland Only)
Angiotensin II Receptor Antagonists FA-EXC®
Angiotensin II Receptor Antagonists FA-EXC® (For Maryland Only)
Aralast NP®
AAT Deficiency
Atacand®
Apokyn®
Aranesp®
Arcalyst®
Atralin®
Aubagio®
Aubagio® (For Maryland Only)
Austedo®
Avastin®
Avastin® (For Maryland Only)
Aveed®
Avita®
Avonex®
Avonex® (For Maryland Only)
Azacitidine®
Bavencio®
Bayer Contour Test Strip®
Bebulin VH®
Bendeka®
Bendeka® (For Maryland Only)
Benefix®
Benlysta®
Benlysta® (For Maryland Only)
Berinert®
Berinert (For Maryland Only)
Betaseron® (For Maryland Only)
Bethkis®
Bexarotene®
Bivigam®
Bivigam® (For Maryland Only)
Blincyto®
Bosulif®
Bosulif® (For Maryland Only)
Botox®
Botox® (For Maryland Only)
Bravelle®
Brineura®
Brineura® (For Maryland Only)
Buphenyl®
Butorphanol®
Cabometyx®
Cabometyx® (for Maryland only)
Capecitabine®
Capecitabine® (For Maryland Only)
Carimune NF®
Carimune NF® (For Maryland Only)
Caprelsa®
Carbaglu®
Cayston®
Cerdelga®
Cerezyme®
Cerezyme® (For Maryland Only)
Cetrotide®
Cholbam®
Cialis®
Cimzia® (Medical)
Cimzia® (Medical) (For Maryland Only)
Cimzia® (Formulary 1 and 2)
Cimzia® (For Maryland Only) (Formulary 1 and 2)
Cimzia® (Formulary 3)
Cimzia® (For Maryland Only) (Formulary 3)
Cinqair®
Cinryze®
Cinryze® (For Maryland Only)
Coagadex®
Cometriq®
Compounded Drug Products®
Contour Test Strips
Copaxone
Copaxone (For Maryland Only)
Copegus®
Corifact®
Cosentyx® (Formulary 1 and 2)
Cosentyx® (For Maryland Only) (Formulary 1 and 2)
Cosentyx® (Formulary 3)
Cosentyx® (For Maryland Only) (Formulary 3)
Cotellic®
Cuvitru
Cystagon®
Cyramza®
Cystaran®
Cytogam®
Daklinza®
Darzalex®
Diabetic Test Strips – Atypical (FA-PA)
Diabetic Test Strips Quantity Limit
Diabetic Test Strips Post Limit
Docefrez®
Docefrez® (For Maryland Only)
Docetaxel®
Docetaxel® (For Maryland Only)
DPP-4 Inhibitors Combinations (FA-EXC)®
DPP-4 Inhibitors Combinations (FA-EXC)® (For Maryland Only)
DPP-4 Inhibitors (FA-EXC)®
DPP-4 Inhibitors (FA-EXC)® (For Maryland Only)
Dupixent®
Dupixent® (For Maryland Only)
Dysport®
Dysport® (For Maryland Only)
Egrifta®
Elaprase®
Elelyso®
Eligard®
Eloctate®
Eloctate® (For Maryland Only)
Eloxatin®
Eloxatin® (For Maryland Only)
Emflaza®
Emflaza® (for Maryland only)
Empliciti®
Emverm®
Enbrel® (Formulary 1 and 2)
Enbrel® (For Maryland Only) (Formulary 1 and 2)
Enbrel® (Formulary 3)
Enbrel® (For Maryland Only) (Formulary 3)
Entresto®
Entyvio® (Medical)
Entyvio® (Medical) (For Maryland Only)
Epogen®
Epoprostenol®
Erbitux®
Erbitux® (For Maryland Only)
Erivedge®
Erwinaze®
Esbriet®
Euflexxa®
Euflexxa® (For Maryland Only)
Exjade®
Exondys 51®
Extavia®
Extavia® (For Maryland Only)
Eylea®
Fabior®
Fabrazyme®
Farxiga (FA-EXC)® (For Maryland Only)
Farydak®
Farydak® (For Maryland Only)
Fasenra® 
Feiba®
Fentanyl Cirtate Oral Tra®
Fentora®
Ferriprox®
Firazyr®
Firmagon®
Flebogamma®
Flebogamma® (For Maryland Only)
Flector (FA-EXC)®
Flector (FA-EXC)® (For Maryland Only)
Flolan®
Follistim AQ®
Forteo®
Forteo® (For Maryland Only)
Fortament®
Fortament® (For Maryland Only)
Freestyle Test Strips
Freestyle Test Strips
Frova® Post Limit
Fuzeon®
GamaSTAN S/D®
GamaSTAN S/D® (For Maryland Only)
Gammagard®
Gammagard® (For Maryland Only)
Gammaked®
Gammaked® (For Maryland Only)
Gammaplex®
Gammaplex® (For Maryland Only)
Gamunex®
Gamunex® (For Maryland Only)
Ganirelix Acetate®
Gattex®
Gattex®
Gazyva®
Gel-One® (For Maryland Only)
Gemzar®
Gemzar® (For Maryland Only)
Genotropin®
Genotropin® (For Maryland Only)
Gilenya®
Gilenya® (For Maryland Only)
Gilotrif®
Glassia®
Glatopa®
Glatopa® (For Maryland Only)
Gleevec®
Glumetza®
Glumetza® (For Maryland Only)
GONAL-F®
GONAL-F RFF®
Granix®
Haegarda®
Haegarda® (For Maryland Only)
Halaven® 
Harvoni®
Helixate®
Helixate® (For Maryland Only)
Helixate® (For Maryland Only)
Hemlibra®
Hemofil M® (For Maryland Only)
Hetlioz®
Hereditary Angioedema
Herceptin®
Herceptin® (For Maryland Only)
Hizentra®
HMG-CoA Reductase Inhibitors (FA-EXC)®
HMG-CoA Reductase Inhibitors (FA-EXC)® (For Maryland Only)
Humate-P®
Humate-P® (For Maryland Only)
Humatrope®
Humira®
Humira® (For Maryland Only)
Hyalgan®
Hyalgan® (For Maryland Only)
Hycamtin®
HyQvia®
Ibrance®
Idelvion®
Iclusig®
Ilaris®
Ilaris® (For Maryland Only)
Imbruvica®
Imbruvica® (For Maryland Only)
Imfinzi®
Imitrex®
Immune Globulins
Increlex®
Inflectra®
Inflectra® (For Maryland Only)
Influenza Treatment
Ingrezza®
Inlyta®
Insomnia Agents (FA-EXC)
Insomnia Agents (FA-EXC)(For Maryland Only)
Intron A®
Intron A® (For Maryland Only)
Iressa®
Ixempra®
Ixinity®
Jadenu®
Jakafi®
Jakafi® (For Maryland Only)
Jevtana® 
Juxtapid®
Juxtapid® (For Maryland Only)
Kadcyla®
Kalbitor®
Kalbitor® (for Maryland only)
Kalydeco®
Kanuma®
Kevzara®
Kevzara® (for Maryland only)
Keytruda®
Kineret® (Formulary 1 and 2)
Kineret® (For Maryland Only) (Formulary 1 and 2)
Kineret® (Formulary 3)
Kineret® (For Maryland Only) (Formulary 3)
Kisqali Femara® Co-Pack
Kitabis Pak®
Kisqali®
Koate-DVI®
Koate-DVI® (For Maryland Only)
Kogenate FS®
Kogenate FS® (For Maryland Only)
Korlym®
Krystexxa®
Kuvan®
Kymriah®
Kynamro®
Kynamro® (For Maryland Only)
Kyprolis®
Lazanda®
Lemtrada®
Lemtrada® (For Maryland Only)
Lenvima®
Lenvima® (For Maryland Only)
Letairis®
Leuprolide Acetate
Lidocaine®
Lonsurf®
Lonsurf® (for Maryland only)
Lovaza®
Lucentis®
Lumizyme®
Lupron®, Hormonal
Luxturna®
Leukine®
Lynparza®
Lynparza® (For Maryland Only)
Macugen®
Makena®
Mekinist®
Menopur®
Mircera®
Mitoxantrone®
Moderiba®
Monoclate-P®
Monoclate-P® (For Maryland Only)
Mononine®
Monovisc®
Monovisc® (For Maryland Only)
Myalept®
Myobloc®
Myozyme®
Naglazyme®
Naprelan (FA-EXC)®
Naprelan (FA-EXC)® (For Maryland Only)
Nasal Steroids (FA-EXC)®
Nasal Steroids (FA-EXC)® (For Maryland Only)
Natpara®
Natesto®
Natesto® (For Maryland Only)
Nerlynx®
Nerlynx® (For Maryland Only)
Neulasta®
Neumega®
Neupogen®
New to Market Drugs;
New to Market Drugs (For Maryland Only)
Ninlaro®
Norditropin Flexpro®
Northera®
Nesina® (For Maryland Only)
Nexavar®
NovoSeven RT®
NovoSeven RT® (For Maryland Only)
Nplate®
Nplate® (For Maryland Only)
Nucala®
Nutropin AQ®
Obizur®
Ocaliva®
Ocaliva® (for Maryland only)
Ocrevus®
Ocrevus® (for Maryland only)
Octagam®
Octagam® (For Maryland Only)
Octreotide Acetate®
Octreotide Acetate® (For Maryland Only)
Odomzo®
Ofev®
Olysio®
Omega 3 Fatty Acids
Omnitrope®
Omnitrope® (For Maryland Only)
Oncaspar®
Onsolis®
Opdivo®
Opioids ER MME Limit and Post Limit
Opioids IR MME Limit and Post Limit
Opsumit®
Oral Pain Meds
Orencia® (Formulary 1 and 2)
Orencia® (For Maryland Only) (Formulary 1 and 2)
Orencia® (Formulary 3)
Orencia® (For Maryland Only) (Formulary 3)
Orenitram®
Orkambi®
Orthovisc®
Orthovisc® (For Maryland Only)
Osteoarthritis 
Osteoarthritis (For Maryland Only)
Orfadin®
Otezla® (Formulary 1 and 2)
Otezla® (For Maryland Only) (Formulary 1 and 2)
Otezla® (Formulary 3)
Otezla® (For Maryland Only) (Formulary 3)
Otrexup®
Otrexup® (For Maryland Only)
Ovidrel®
Pegasys®
Peg-Intron®
Pennsaid®
Perjeta®
Plegridy®
Plegridy® (For Maryland Only)
Pomalyst®
Pomalyst® (For Maryland Only)
Praluent®
Praluent® (For Maryland Only)
Pregnyl®
Privigen®
Privigen® (For Maryland Only)
Procrit®
Procysbi®
Procysbi® (For Maryland Only)
Prolastin-C®
Prolia®
Prolia® (Medical)
Prolia® (For Maryland Only)
Promacta®
Promacta® (For Maryland Only)
Proton Pump Inhibitors (FA-EXC)®
Provenge® (For Maryland Only)
Prudoxin®, Zonalon® (Step Therapy)
Pulmozyme®
Radicava®
Rasuvo®
Rasuvo® (For Maryland Only)
Ravicti®
Rebetol®
Reclast®
Reclast® (For Maryland Only)
Recombinate®
Recombinate® (For Maryland Only)
Regranix®
Remicade®
Remicade® (For Maryland Only)
Remicade®, Inflectra®, Renflexis® (Formulary 3)
Remicade®, Inflectra®, Renflexis® (For Maryland Only) (Formulary 3)
Remodulin®
Repatha®
Repatha® (For Maryland Only)
Replax Post Limit®
Repronex®
Retin-A®
Revatio®
Revlimid®
Rebif (FA-EXC)®
Rebif (FA-EXC)® (For Maryland Only)
RiaSTAP®
Ribasphere®
Ribavirin®
Rituxan®
Rituxan® Oncology
Rituxan® (For Maryland Only)
Rixubis®
Rubraca®
Rubraca® (For Maryland Only)
Ruconest®
Ruconest® (For Maryland Only)
Rydapt®
SABAs (FA-EXC)®
SABAs (FA-EXC)® (For Maryland only)
Sabril®
Sabril® (For Maryland Only)
Saizen®
Samsca®
Sandostatin®
Serostim®
Serostim® (For Maryland Only)
Sensipar®
Signifor LAR®
Sildenafil®
Siliq® (Formulary 1 and 2)
Siliq® (For Maryland Only) (Formulary 1 and 2)
Siliq® (Formulary 3)
Siliq® (For Maryland Only) (Formulary 3)
Simponi®, Simponi Aria® (Formulary 1 and 2)
Simponi®, Simponi Aria® (For Maryland Only) (Formulary 1 and 2)
Simponi®, Simponi Aria® (Formulary 3)
Simponi®, Simponi Aria® (For Maryland Only) (Formulary 3)
Sodium Phenylbutyrate
Solaraze®
Soliris®
Solodyn®
Solodyn® (For Maryland Only)
Somatuline Depot®
Somavert®
Sovaldi®
Sovaldi® (For Maryland Only)
Spinraza®
Sprycel®
Stelara® (Medical)
Stelara® (Medical) (For Maryland Only)
Stelara® (Formulary 1 and 2)
Stelara® (For Maryland Only) (Formulary 1 and 2)
Stelara® (Formulary 3)
Stelara® (For Maryland Only) (Formulary 3)
Stimate®
Stivarga®
Stivarga® (For Maryland Only)
Strensiq®
Subsys®
Supartz®
Supartz® (For Maryland Only)
Supprelin LA®
Sutent®
Sylatron®
Synvisc®
Synvisc® (for Maryland only)
Tafinlar®
Tagrisso®
Tagrisso® (for Maryland only)
Tamiflu Post Limit®
Taltz® (Formulary 1 and 2)
Taltz® (for Maryland only) (Formulary 1 and 2)
Taltz® (Formulary 3)
Taltz® (for Maryland only) (Formulary 3)
Tarceva®
Targretin®
Tasigna®
Tasigna® (For Maryland Only)
Taxotere®
Taxotere® (For Maryland Only)
Tazorac®
Tecentriq®
Tecfidera®
Tecfidera® (For Maryland Only)
Technivie®
Technivie® (For Maryland Only)
Temodar®
Temozolomide®
Testosterone Products (FA-EXC)
Testosterone Products (FA-EXC) (For Maryland Only)
Tetrabenazine®
Thalomid®
Tikosyn®
TOBI®
Tobramycin®
Tracleer®
Treanda®
Treanda® (For Maryland Only)
Trelstar®
Tremfya® (Formulary 1 and 2)
Tremfya® (For Maryland Only) (Formulary 1 and 2)
Tremfya® (Formulary 3)
Tremfya® (For Maryland Only) (Formulary 3)
Tretten®
Tretin-X®
Treximet Post Limit®
Trentinoins
Tykerb®
Tymlos®
Tymlos® (For Maryland Only)
Tysabri®
Tysabri® (For Maryland Only)
Tyvaso®
Uptravi®
Valchlor®
Vantas®
Vascepa®
Vectibix®
Velcade®
Veletri®
Venclexta®
Venclexta® (For Maryland Only)
Ventavis®
Victrelis®
Vidaza®
Viekira Pak®
Viekira Pak® (For Maryland Only)
Vimizim®
Visco-3®
Visco-3® (Maryland Only)
Visudyne®
Vonvendi®
Vosevi®
Vosevi® (For Maryland Only)
Votrient®
VPRIV®
VPRIV® (For Maryland Only)
Wilate®
Wilate® (For Maryland Only)
Xartemis® XR MME Limit
Xalkori®
Xeljanz® (Formulary 1 and 2)
Xeljanz® (For Maryland Only) (Formulary 1 and 2)
Xeljanz®, Xeljanz XR® (Formulary 3)
Xeljanz®, Xeljanz XR® (For Maryland Only) (Formulary 3)
Xeloda®
Xenazine®
Xeomin®
Xeomin® (For Maryland Only)
Xermelo®
Xermelo® (for Maryland only)
Xgeva®
Xgeva® (For Maryland Only)
Xifaxan®
Xolair®
Xolair® (For Maryland Only)
Xtandi®
Xyntha®
Xyntha® (For Maryland Only)
Yervoy®
Zarxio®
Zavesca®
Zejula®
Zelboraf®
Zemaira®
Zoladex®
Zoledronic Acid®
Zomacton®
Zometa®
Zolinza®
Zorbtive®
Zydelig®
Zykadia®
Zytiga®