Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
Actemra (Arizona) Prior Authorization Form - Community Plan
Last Published 06.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Acthar Gel Prior Authorization Form - Community Plan
Last Published 09.14.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Iowa UnitedHealthcare Community Plan - IA Health Link, Iowa UnitedHealthcare Community Plan Hawk-i, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, Ohio UnitedHealthcare Community Plan
Actimmune (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.07.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
ADHD Products (Arizona) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Afinitor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Afrezza (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.31.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Alecensa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Alfa Interferons (Arizona) Prior Authorization Form - Community Plan
Last Published 01.02.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Alinia (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Alunbrig (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Alzheimer's Agents (Arizona) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Ampyra (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Anthelmintics (Arizona) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Anticonvulsants (AZ, FL, HI, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 09.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Antiemetics (Arizona) Prior Authorization Form - Community Plan
Last Published 01.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Antipsoriatic Agents [e.g. Calcipotriene, Calcitriol] (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.01.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Antipsychotics (Arizona) Prior Authorization Form - Community Plan
Last Published 03.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Apokyn (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Aquadeks (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Arcalyst (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.23.2019
Use this paper fax form to submit requests for the following state plans: Arizona, Florida Healthy Kids, Hawaii, Maryland, New Jersey, New York, New York EPP, Ohio, Pennsylvania, Rhode Island
Aricept 23mg [Donepezil] (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Arikayce (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 06.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Austedo (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 05.01.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Azole Antifungals (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.17.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Belbuca / Butrans (Arizona) Prior Authorization Form - Community Plan
Last Published 04.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Benlysta (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 09.20.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Healthy Louisiana Plan, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Benznidazole (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 07.31.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania Community Plan, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Biltricide (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Bonjesta / Diclegis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Bosulif (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Braftovi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Breast Cancer Agents (Arizona) Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Brilinta & Effient (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 10.19.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care,Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, UnitedHealthcare Connected® for MyCare Ohio, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Buphenyl (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Cablivi (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Cabometyx (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 06.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Calcitonin Gene-Related Peptide [CGRP] (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.17.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Calquence (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Caprelsa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Carbaglu (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.20.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Cayston (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Celebrex Prior Authorization Form - Community Plan
Last Published 09.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Cesamet / Marinol / Syndros (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Cholbam (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.29.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Cialis for Benign Prostatic Hyperplasia (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 09.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Florida Community Plan M*Plus (MMA), Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Cimzia (Arizona) Prior Authorization Form - Community Plan
Last Published 06.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Cinryze (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Ciprodex (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 06.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Colony Stimulating Factors (Arizona) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Combination DDP4 & SGLT2 (Arizona) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Cometriq (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Complera Prior Authorization Form - Community Plan
Last Published 12.20.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Compound Medications Prior Authorization Form - Community Plan
Last Published 04.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Constipation Agents (Arizona) Prior Authorization Form - Community Plan
Last Published 09.17.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Copiktra (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Copper Chelating Agents (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Corlanor Prior Authorization Form - Community Plan
Last Published 04.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Cosentyx (Arizona) Prior Authorization Form - Community Plan
Last Published 04.24.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Cotellic (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Crestor (Arizona) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Cystaran Prior Authorization Form - Community Plan
Last Published 07.31.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Daraprim (AZ, Florida Healthy Kids, HI, OH) Prior Authorization Form - Community Plan
Last Published 07.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Ohio UnitedHealthcare Community Plan
Dificid (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Doptelet (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
DPP-4 Inhibitors (Arizona) Prior Authorization Form - Community Plan
Last Published 01.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Dry Eye Disease [Restasis & Xiidra] (AZ, FL, HI, MD, NJ, NY, OH, PA) Prior Authorization Form - Community Plan
Last Published 06.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids
Duexis and Vimovo (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.26.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Duopa (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.20.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Dupixent (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Egrifta (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.20.2018
Use this paper fax form to submit requests for the following state plans: Arizona, Florida Healthy Kids, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island and Washington
Elidel / Protopic (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania) Prior Authorization Form - Community Plan
Last Published 01.02.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids
Elmiron (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Emflaza (Arizona) Prior Authorization Form - Community Plan
Last Published 09.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Enbrel (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program,
Endari Prior Authorization Form - Community Plan
Last Published 12.20.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Entocort EC (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Entresto Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Erivedge (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Erleada (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Erythropoietic Agents [e.g. Aranesp, Epogen, Procrit, Mircera] (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Eucrisa Prior Authorization Form - Community Plan
Last Published 04.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Exondys 51 (Arizona) Prior Authorization Form - Community Plan
Last Published 09.24.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Fenofibrate (AZ, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Firazyr (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.09.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Firdapse (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Fortamet, GlucophageXR, Glumetza (Arizona) Prior Authorization Form - Community Plan
Last Published 10.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Forteo (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 11.01.2018
Use this paper fax form to submit requests for the following state plans: Arizona, Florida Healthy Kids, Hawaii, Maryland, New Jersey, New York, Ohio, Rhode Island
Galafold (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Gilotrif (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Gleevec (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
GLP-1 Agonist / Basal Insulin Combinations (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
GLP-1 Agonists (Arizona) Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Gonadotropin-Releasing Hormone Agonists (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
H.P. Acthar Gel (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 01.23.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Haegarda (Arizona) Prior Authorization Form - Community Plan
Last Published 01.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Hemangeol (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.21.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Healthy Louisiana Plan, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Hemlibra (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Hemophilia Treatments (Arizona) Prior Authorization Form - Community Plan
Last Published 03.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Hepatitis B (Arizona) Prior Authorization Form - Community Plan
Last Published 01.02.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Hepatitis C Medications (Arizona) Prior Authorization Form - Community Plan
Last Published 05.02.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Hetlioz Prior Authorization Form - Community Plan
Last Published 01.09.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Human Chorionic Gonadotropin (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 11.02.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Healthy Louisiana Plan, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Humira (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 10.01.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Hycamtin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Ibrance (AZ, Florida Chip, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 11.02.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Iclusig (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Idhifa (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Idiopathic Pulmonary Fibrosis [e.g. Esbriet, Ofev] (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.26.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, UnitedHealthcare Connected® for MyCare Ohio, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Ilaris (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.26.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Ilumya (Arizona) Prior Authorization Form - Community Plan
Last Published 03.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Imbruvica (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Ingrezza Prior Authorization Form - Community Plan
Last Published 04.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Inhaled Corticosteroid/Long Acting Beta Agonist Combinations [Advair, Dulera, Symbicort, Breo Ellipta, AirDuo] (Arizona) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Prior Authorizations form for Inhaled Corticosteroids/Long-Acting Beta Agonist Combinations - Advair, Dulera, Symbicort, Breo Ellipta and AirDuo. Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care.
Inhaled Corticosteroids [Arnuity / Ellipta / Asmanex HFA / Pulmicort Respules] (Arizona) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Inlyta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Insulin Pen Needles and Syringes (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Iressa (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Irritable Bowel Syndrome - Diarrhea [e.g. Lotronex, Vibrezi] (AZ, Florida Healthy Kids, HI, MD, NJ, NY, RI) Prior Authorization Form - Community Plan
Last Published 09.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Jakafi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 06.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Juxtapid (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Jynarque (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Kalydeco (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Keveyis (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Kevzara (Arizona) Prior Authorization Form - Community Plan
Last Published 08.12.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Kineret (Arizona) Prior Authorization Form - Community Plan
Last Published 07.08.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Kisqali (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Kisqali Femara Co-Pack (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.23.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Korlym (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 06.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Kynamro (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Lenvima (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Leucovorin (Arizona) Prior Authorization Form - Community Plan
Last Published 01.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Lidocaine Patch (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 11.02.2018
Use this paper fax form to submit requests for the following states: Arizona, Hawaii, Maryland, New Jersey, New York (Community Plan, Essential and Wellness4Me only), Ohio, Pennsylvania, Rhode Island, Washington
Lokelma / Veltassa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Lonhala Magnair / Yupelri (Arizona) Prior Authorization Form - Community Plan
Last Published 03.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Lonsurf (AZ, FLCHP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.26.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Lorbrena (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.02.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Lucemyra (AZ, FL, HI, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Lynparza (AZ, FL CHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.23.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Lyrica (AZ, FL, HI, NJ, NY, OH, PA) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids
Lysteda (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Makena (Arizona) Prior Authorization Form - Community Plan
Last Published 06.05.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Mekinist (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 08.12.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, FLorida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Mektovi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Migranal Nasal Spray (AZ, FL CHIP, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 09.24.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Mirvaso (AZ, FL, HI, MD, NJ, NY, OH, PA) Prior Authorization Form - Community Plan
Last Published 03.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids
Mozobil Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following states: Arizona, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Washington
MS Agents [Multiple Sclerosis] (Arizona) Prior Authorization Form - Community Plan
Last Published 01.02.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Mulpleta (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Multaq (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Mytesi (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program,Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Namzaric (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 11.02.2018
Use this paper fax form to submit requests for the following state plans: Arizona, Florida Healthy Kids, Hawaii, Maryland, New Jersey, New York, New York EPP, Ohio, Rhode Island
Natpara (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Nerlynx (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Nexavar (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.14.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Ninlaro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.23.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Noctiva & Nocdurna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Northera (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 11.05.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Nuedexta (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, UnitedHealthcare Connected® for MyCare Ohio, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Nuplazid (Arizona, Florida, Hawaii, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Odomzo (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Olumiant (Arizona) Prior Authorization Form - Community Plan
Last Published 01.02.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Omega [e.g. Lovaza, Epanova, Omtryg, Vascepa] (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Opioid Products (Arizona) Prior Authorization Form - Community Plan
Last Published 09.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Orencia (Arizona) Prior Authorization Form - Community Plan
Last Published 09.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Orilissa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.25.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Osphena (FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorizatio Form - Community Plan
Last Published 09.30.2019
se this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice,
Otezla (Arizona) Prior Authorization Form - Community Plan
Last Published 10.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Overactive Bladder (OAB) Agents (Arizona) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Oxervate (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Palynziq (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Panretin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Pomalyst (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Praluent (AZ, HI, MD, NJ, NY, OH, RI, WA) Prior Authorization Form - Community Plan
Last Published 04.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Prevymis (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Procysbi (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.09.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Promacta (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Proton Pump Inhibitors (Arizona) Prior Authorization Form - Community Plan
Last Published 04.27.2018
Use this paper fax form to submit requests for the following states: Arizona
Provigil / Nuvigil (AZ, FL, HI, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.11.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Pulmozyme (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 11.05.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Ranexa Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following states: Arizona, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania
Ravicti (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Rectiv (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.17.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Regranex (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Relistor Prior Authorization Form - Community Plan
Last Published 04.05.2019
Use this paper fax form to submit requests for the following states: Arizona, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Washington
Renvela Prior Authorization Form - Community Plan
Last Published 04.05.2019
Use this paper fax form to submit requests for the following states: Arizona, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Washington
Repatha (AZ, FL, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Revlimid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.07.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Rhofade (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania) Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids
Rubraca (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Ruconest (AZ, FLCHIP, HI, MD, NJ, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 10.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Rydapt (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.02.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Samsca (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Sandostatin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.23.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Sedative Hypnotics (Arizona) Prior Authorization Form - Community Plan
Last Published 12.26.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
SGLT-2 Inhibitors (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA) Prior Authorization Form - Community Plan
Last Published 11.06.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids
Siliq (Arizona) Prior Authorization Form - Community Plan
Last Published 04.23.2018
Use this paper fax form to submit requests for the following states: Arizona
Simponi, Subcutaneous (Arizona) Prior Authorization Form - Community Plan
Last Published 10.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Sivextro (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Soliris (Arizona) Prior Authorization Form - Community Plan
Last Published 10.09.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Somavert (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Soriatane (AZ, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following states: Hawaii, Maryland and New York
Spinraza (Arizona) Prior Authorization Form - Community Plan
Last Published 10.08.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Sprycel (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Stelara (Arizona) Prior Authorization Form - Community Plan
Last Published 04.15.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Stivarga (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Strensig (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 11.06.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Essential Plan, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Suboxone (Arizona) Prior Authorization Form - Community Plan
Last Published 10.19.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Subutex (Arizona) Prior Authorization Form - Community Plan
Last Published 10.19.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Sylatron & Intron A (Arizona) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Symlin (AZ, FL, HI, MD, NJ, NY, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Synagis Prior Authorization Form - Community Plan
Last Published 10.08.2019
Please complete this entire form for UnitedHealthcare Community Plan members needing a Synagis prescription and fax it to the UnitedHealthcare Community Plan Prior Authorization Department.
Synribo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Tafinlar (AZ, Florida Healthy Kids, HI, MD, NY, OH, RI) Prior Authorization Form - Community Plan
Last Published 09.27.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Tagrisso (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Takhzyro (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Taltz (Arizona) Prior Authorization Form - Community Plan
Last Published 05.02.2018
Use this paper fax form to submit requests for the following states: Arizona
Talzenna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 09.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare Rite Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Tarceva (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Targretin (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Tasigna (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Tavalisse (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Tegsedi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Temodar (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.28.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Test Strips (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.02.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Testosterone Products [Topical Androgens] (Arizona) Prior Authorization Form - Community Plan
Last Published 05.06.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Thalomid (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.07.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Tibsovo (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Topical NSAIDs (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Topical Retinoid Products (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Trelegy Ellipta (Arizona) Prior Authorization Form - Community Plan
Last Published 01.03.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Tremfya (Arizona) Prior Authorization Form - Community Plan
Last Published 05.02.2018
Use this paper fax form to submit requests for the following states: Arizona
Tretinoin Capsules (Arizona) Prior Authorization Form - Community Plan
Last Published 12.31.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Triptans (Arizona) Prior Authorization Form - Community Plan
Last Published 01.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Tykerb (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.31.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Uloric (AZ, HI, Florida Healthy Kids, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Valchlor (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Vancocin (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 12.28.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Vancomycin (Arizona) Prior Authorization Form - Community Plan
Last Published 01.29.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Vecamyl (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 12.27.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Vemlidy (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.09.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Venclexta (AZ, FLCHIP, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 10.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Verzenio (AZ, HI, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 11.07.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Vitrakvi (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Vizimpro (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Votrient (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.19.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Xalkori (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Xeljanz/Xeljanz XR (Arizona) Prior Authorization Form - Community Plan
Last Published 10.10.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Xenazine (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.30.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Xifaxan (AZ, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.07.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Xolair (AZ, HI, LA, MD, NJ, NY, OH, PA, RI, WA) Prior Authorization Form - Community Plan
Last Published 01.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Healthy Louisiana Plan, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion, Washington UnitedHealthcare Community Plan
Xospata (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.16.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Xtandi (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Xyrem (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 04.22.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Yonsa (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Zejula (AZ, HI, MD, NJ, NM, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 10.23.2018
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Zelboraf (AZ, Florida Healthy Kids, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 07.09.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Zolinza (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.05.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Zontivity (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.01.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Zydelig (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 01.23.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Zykadia (Arizona, Florida, Hawaii, Maryland, New Jersey, New York, Ohio, Pennsylvania, Rhode Island) Prior Authorization Form - Community Plan
Last Published 01.04.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Zytiga (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 03.18.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
Zyvox (AZ, FL, HI, MD, NJ, NY, OH, PA, RI) Prior Authorization Form - Community Plan
Last Published 02.19.2019
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Florida Healthy Kids, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me, Ohio UnitedHealthcare Community Plan, Pennsylvania UnitedHealthcare Community Plan for Families, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion