Recent Updates to Pharmacy PA Forms and Criteria

Over the past couple of months, updates and additions have been made to pharmacy forms and criteria. Providers are encouraged to review the recent updates and make sure they are using the most current editions of the documents, which can be found under the Pharmacy Services web page on either the Prior Approval Drugs and Criteria or Drug Request Forms page.

 

Added

Harvoni Initial and Continuation PA forms – previously only electronic, now offered as a paper form as well

 

Updated

Fasenra PA form

Emflaza PA Form

Emflaza PA Criteria – (2 years of age and up)

Migraine Calcitonin Gene Therapy PA form

Migraine Calcitonin Gene Therapy PA Criteria

Immunomodulators PA Criteria (adding Siliq and Stelara Infusion)

Crohn’s (Adult) PA Form – (adding Stelara Infusion)

Plaque Psoriasis (Adult) PA Form

BH Clinical PA Criteria (Adult)

BH Clinical PA Criteria (Pediatric)