Ankylosing Spondylitis (Enbrel, Humira, Simponi, and Cimzia)

Prior Authorization Form

• English

Botox, Dysport, Myobloc, and Xeomin

Prior Authorization Form

• English

Crinone 8% Gel

Prior Authorization Form

• English

Cryopyrin-Associated Periodic Syndromes (Kineret)

Prior Authorization Form

• English

Dupixent for Atopic Dermatitis

Prior Authorization Form

• English

Emflaza

Prior Authorization Form

• English

Exondys 51

Prior Authorization Form

• English

Growth Hormone (Adult 21 Years of Age and Older)

Prior Authorization Form

• English

Hidradenitis Suppurativa (Humira)

Prior Authorization Form

• English

Juvenile Idiopathic Arthritis (Actemra SQ, Enbrel, Humira, and Orencia SQ)

Prior Authorization Form

• English

Lidoderm

Prior Authorization Form

• English

Mavyret (Continuation)

Prior Authorization Form

• English

Monoclonal Antibody Therapy (Nucala)

Prior Authorization Form

• English

Neonatal Onset Multi-System Inflammatory Disease (Kineret)

Prior Authorization Form

• English

Non-Steroidal Anti-inflammatory Drugs including Cox-2 Inhibitors

Prior Authorization Form

• English

Opioid Analgesic (Short-Acting)

Prior Authorization Form

• English

Plaque Psoriasis (Enbrel, Humira, and Stelara)

Prior Authorization Form

• English

Polyarticular Juvenile Idiopathic Arthritis (Actemra SQ, Enbrel, Humira, and Orencia SQ)

Prior Authorization Form

• English

Provigil and Nuvigil

Prior Authorization Form

• English

Psoriatic Arthritis (Otezla)

Prior Authorization Form

• English

Sedative Hypnotics

Prior Authorization Form

• English

Symdeko

Prior Authorization Form

• English

Treatment for Movement Disorders (Ingrezza)

Prior Authorization Form

• English

Ulcerative Colitis (Humira and Simponi)

Prior Authorization Form

• English

Vusion

Prior Authorization Form

• English