PDL Prior Authorization Request Fax Form  

(For prescribers to use for faxing preauthorization requests)

PDL Medication Change Fax Form  

(For pharmacists to use to notify prescribers or preferred alternatives and preauthorization requirements)

Preferred Drug List Forms

Fentanyl buccal Pre-authorization form

(For prescriber's statement of criteria for fentanyl buccal and lozenges)

Antimigraine (Triptan) Quantity Override Pre-Authorization

(For prescriber's to request an authorization to override maximum allowable quantities for antimigraine triptan drugs)

Growth Hormone (GH) Pre-Authorization Request Form   

(For prescribers Statement of medical necessity for growth hormones)

[DHMH] Medwatch Form   

(For prescribers to use for attesting to justifications for "Brand Medically Necessary")

Revlimid™ (lenalidomide) Pre-Authorization Form 

(For prescribers to certify that patient is not part of a clinical study of this drug)

Serostim® Treatment of AIDS Wasting Syndrome  

(For prescribers statement of medical necessity for Serostim treatment)

Synagis® (palivizumab) Pre-Authorization Form & Billing Instructions

(For prescriber's statement of medical necessity for Synagis - palivizumab)

Invoices

Pharmacy Compounding

Clotting Factor and High-Cost Drugs

Clotting Factor and High-Cost Drug Standard Invoice

(Required for reimbursement of clotting factor and charges exceeding $2,500)