Virginia Community Plan Pharmacy Prior Authorization Forms
Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
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Actimmune (Virginia) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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ADHD Medications, Non-Stimulant (Virginia) Prior Authorization Form - Community Plan
Last Published 05.06.2019
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ADHD Medications, Stimulant (Virginia) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Afinitor (Virginia) Prior Authorization Form - Community Plan
Last Published 11.05.2018
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Alunbrig (Virginia) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Anthelminitics (Virginia) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Anti-Allergens, Oral (Virginia) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Anti-Emetic / Anti-Vertigo Agents (Virginia) Prior Authorization Form - Community Plan
Last Published 01.31.2019
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Anti-Migraine Agents (Virginia) Prior Authorization Form - Community Plan
Last Published 09.25.2019
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Anti-Obesity Drugs [e.g. Adipex-P, Belviq, Saxenda] (Virginia) Prior Authorization Form - Community Plan
Last Published 06.29.2018
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AquADEKs (Virginia) Prior Authorization Form - Community Plan
Last Published 09.23.2019
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Arcalyst (Virginia) Prior Authorization Form - Community Plan
Last Published 09.23.2019
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Arikayce (Virginia) Prior Authorization Form - Community Plan
Last Published 06.05.2019
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Austedo (Virginia) Prior Authorization Form - Community Plan
Last Published 05.01.2019
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Benlysta (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Bosulif (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Braftovi (Virginia) Prior Authorization Form - Community Plan
Last Published 03.18.2019
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Cablivi (Virginia) Prior Authorization Form - Community Plan
Last Published 09.25.2019
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Cabometyx (Virginia) Prior Authorization Form - Community Plan
Last Published 09.24.2019
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Calquence (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Cerdelga / Zavesca (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Colony Stimulating Factors (Virginia) Prior Authorization Form - Community Plan
Last Published 01.31.2019
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Cometriq (Virginia) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Copiktra (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Cotellic (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Cystaran (Virginia) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Daraprim (Virginia) Prior Authorization Form - Community Plan
Last Published 05.25.2018
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Daurismo (Virginia) Prior Authorization Form - Community Plan
Last Published 03.19.2019
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Dermatologic Acne Agents (Virginia) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Doptelet (Virginia) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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Dronabinol (Virginia) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Erivedge (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Firdapse (Virginia) Prior Authorization Form - Community Plan
Last Published 04.15.2019
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Galafold (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Genvoya / Stribild (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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GI Antibiotics (Virginia) Prior Authorization Form - Community Plan
Last Published 01.04.2019
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GI Motility, Chronic [Amitiza, Linzess, Lotronex, Movantik, Relistor, Trulance, Viberzi] (Virginia) Prior Authorization Form - Community Plan
Last Published 01.28.2019
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Gleevec (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Gonadotropin-Releasing Hormone Agonists (Virginia) Prior Authorization Form - Community Plan
Last Published 01.29.2019
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Growth Hormone Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 02.07.2019
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Hemlibra (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Hepatitis C Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 09.27.2019
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Hetlioz (Virginia) Prior Authorization Form - Community Plan
Last Published 05.03.2018
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HIV (Virginia) Prior Authorization Form - Community Plan
Last Published 10.01.2019
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Hycamtin (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Iclusig (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Idhifa (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Ilaris (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Imbruvica (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Immunomodulators, Atopic Dermatitis (Virginia) Prior Authorization Form - Community Plan
Last Published 09.26.2019
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Increlex (Virginia) Prior Authorization Form - Community Plan
Last Published 05.02.2018
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Inderal LA (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Ingrezza (Virginia) Prior Authorization Form - Community Plan
Last Published 01.31.2019
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Insulins (Virginia) Prior Authorization Form - Community Plan
Last Published 04.16.2019
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Iressa (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Isotrentinoin (Virginia) Prior Authorization Form - Community Plan
Last Published 09.26.2019
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Jakafi (Virginia) Prior Authorization Form - Community Plan
Last Published 06.05.2019
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Kisqali Femara Co-Pack (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Kuvan (Virginia) Prior Authorization Form - Community Plan
Last Published 04.24.2018
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Lenvima (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Lokelma / Veltassa (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Long-Acting Beta Adrenergics (Virginia) Prior Authorization Form - Community Plan
Last Published 04.24.2018
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Lonhala (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Lonsurf (Virginia) Prior Authorization Form - Community Plan
Last Published 09.26.2019
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Lorbrena (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Lucemyra (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Macrolides / Ketolides (Virginia) Prior Authorization Form - Community Plan
Last Published 04.25.2018
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Mekinist (Virginia) Prior Authorization Form - Community Plan
Last Published 08.12.2019
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Mektovi (Virginia) Prior Authorization Form - Community Plan
Last Published 03.18.2019
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Migranal (Virginia) Prior Authorization Form - Community Plan
Last Published 05.01.2019
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Mulpleta (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Multiple Scelorsis (MS) Agents (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Nerlynx (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Noctiva & Nocdurna (Virginia) Prior Authorization Form - Community Plan
Last Published 01.31.2019
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Opioid Dependency (Virginia) Prior Authorization Form - Community Plan
Last Published 10.09.2019
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Opioid Products (Virginia) Prior Authorization Form - Community Plan
Last Published 10.15.2019
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Oral Hypoglycemics (Virginia) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Orilissa (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Orkambi (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Oxervate (Virginia) Prior Authorization Form - Community Plan
Last Published 04.16.2019
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Palynziq (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Panretin (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Phosphodiesterase 5 Inhibitors (Virginia) Prior Authorization Form - Community Plan
Last Published 04.26.2018
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Platelet Inhibitors, Durlaza / Yosprala / Zontivity (Virginia) Prior Authorization Form - Community Plan
Last Published 05.07.2018
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Pomalyst (Virginia) Prior Authorization Form - Community Plan
Last Published 10.18.2018
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Prevymis (Virginia) Prior Authorization Form - Community Plan
Last Published 12.20.2018
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Provigil / Nuvigil (Virginia) Prior Authorization Form - Community Plan
Last Published 04.27.2018
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Regranex (Virginia) Prior Authorization Form - Community Plan
Last Published 01.31.2019
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Revlimid (Virginia) Prior Authorization Form - Community Plan
Last Published 10.18.2018
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Rubraca (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Rydapt (Virginia) Prior Authorization Form - Community Plan
Last Published 12.26.2018
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Sandostatin (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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SGLT-2 Inhibitors (Virginia) Prior Authorization Form - Community Plan
Last Published 08.08.2018
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Sivextro (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Soriatane (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Sprycel (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Stivarga (Virginia) Prior Authorization Form - Community Plan
Last Published 12.28.2018
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Strensiq (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Sutent (Virginia) Prior Authorization Form - Community Plan
Last Published 10.10.2019
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Synagis Prior Authorization Form - Community Plan
Last Published 10.08.2019
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Tafinlar (Virginia) Prior Authorization Form - Community Plan
Last Published 10.10.2019
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Takhzyro (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Talzenna (Virginia) Prior Authorization Form - Community Plan
Last Published 10.02.2019
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Tarceva (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Targretin (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Tasigna (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Tegsedi (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Temodar (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Thalomid (Virginia) Prior Authorization Form - Community Plan
Last Published 10.19.2018
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Tibsovo (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Topical Androgens (Virginia) Prior Authorization Form - Community Plan
Last Published 05.03.2018
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Tykerb (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Valchlor (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Venclexta (Virginia) Prior Authorization Form - Community Plan
Last Published 10.10.2019
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Vitrakvi (Virginia) Prior Authorization Form - Community Plan
Last Published 03.18.2019
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Vizimpro (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Xalkori (Virginia) Prior Authorization Form - Community Plan
Last Published 03.18.2019
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Xenazine (Virginia) Prior Authorization Form - Community Plan
Last Published 01.31.2019
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Xifaxan (Virginia) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Xolair (Virginia) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Xtandi (Virginia) Prior Authorization Form - Community Plan
Last Published 02.06.2019
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Yonsa (Virginia) Prior Authorization Form - Community Plan
Last Published 03.19.2019
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Zelboraf (Virginia) Prior Authorization Form - Community Plan
Last Published 07.09.2019
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Zydelig (Virginia) Prior Authorization Form - Community Plan
Last Published 02.18.2019
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Zytiga (Virginia) Prior Authorization Form - Community Plan
Last Published 03.19.2019
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Zyvox (Virginia) Prior Authorization Form - Community Plan
Last Published 02.19.2019