Prior Authorization Forms for Pharmacy Services
Therapeutic Class Tables »
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
- Anticonvulsant [11/09/09] (PDF) | TEXT
- Antidepressant [08/03/09] (PDF) | TEXT
- Antipsychotic [08/03/09] (PDF) | TEXT
- Erythropoietin [07/01/05] (PDF) | RTF
- Forteo [07/01/05] (PDF) | RTF
- Growth Hormone Adult [09/01/08] (PDF) | TEXT
- Growth Hormone Pediatric [07/01/08] (PDF) | TEXT
- Hypnotics [11/09/09] (PDF) | TEXT
- Immune Globulin Intravenous (IGIV) [04/15/05] (PDF) | TEXT
- Lipid Lowering Agents Prior Authorization Request [08/03/09] (PDF) | TEXT
- Narcotic [11/09/09] (PDF) | (TEXT)
- Nonsteroidal Anti-Inflammatory Drugs (NSAID) [08/03/09] (PDF) | RTF
- Oral Anti-infectives Prior Authorization Request [05/04/09] (PDF) | TEXT
- Proton Pump Inhibitor [08/03/09] (PDF) | TEXT
- Strattera and Cerebral Stimulant [05/04/09] (PDF) | TEXT
- Suboxone/Subutex Prior Authorization Request [11/09/09] (PDF) | TEXT
- Triptan [02/02/09] (PDF) | TEXT
- Trofile Assay and Selzentry (maraviroc) Prior Authorization Request [12/17/07] (PDF) | TEXT
- Brand-Name Drug (Use this form when requesting prior authorization for any other brand-name drug when there is an FDA "A"-rated generic available.) [07/01/08] (PDF) | RTF
- Drug (Use this form when requesting prior authorization for any drug.) [07/01/08] (PDF) | RTF
This information is provided by MassHealth.