Archived Pharmacy-Related Forms and Completion Instructions

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Archived Pharmacy-Related Forms and Completion Instructions

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Archived January 1, 2014

Form Name	Effective Dates	Associated Online Handbook Archive (if applicable)
Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitor , F-11056 (10/11) Completion Instructions , F-11056A (07/12)	10/01/11-12/31/13	Published policy through 12/31/13
Prior Authorization Drug Attachment for Diabetic Supplies , F-00239 (04/10) Completion Instructions, F-00239A (07/12)	04/01/10-12/31/13	Published policy through 12/31/13
Prior Authorization Drug Attachment for Modafinil ^® and Nuvigil ^® , F-00079 (12/12) Completion Instructions , F-00079A (12/12)	01/01/13-12/31/13	Published policy through 12/31/13
Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis , F-11306 (12/12) Completion Instructions , F-11306A (12/12)	01/01/13-12/31/13	Published policy through 12/31/13
Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis , F-00694 (12/12) Completion Instructions , F-00694A (12/12)	01/01/13-12/31/13	Published policy through 12/31/13
Prior Authorization/Preferred Drug List (PA/PDL) for Elidel and Protopic Drugs , F-11303 (10/11) Completion Instructions , F-11303A (07/12)	10/01/11-12/31/13	Published policy through 12/31/13

Archived March 1, 2014

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 6 Years of Age and Younger , F-00556 (01/12)
- Completion Instructions , F-00556A (07/12)

01/01/12 - 02/28/14

Published policy
through 02/28/14

Archived July 1, 2014

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization / Preferred Drug List (PA/PDL) For Anticoagulants, Oral , F-00806 (07/13)
- Completion Instructions , F-00806A (07/13)

07/01/13 - 06/30/14

Published policy
through 06/30/14

Prior Authorization / Preferred Drug List (PA/PDL) for Zetia or Vytorin , F-00279 (10/11)
- Completion Instructions , F-00279A (07/12)

10/01/11 - 06/30/14

Published policy
through 06/30/14

Prior Authorization Drug Attachment for Incivek and Victrelis , F-00583 (3/12)
- Completion Instructions , F-00583A (7/12)

3/01/12 - 06/30/14

Published policy
through 06/30/14

Prior Authorization / Preferred Drug List (PA/PDL) For Multiple Sclerosis (MS) Agents, Immunomodulators , F-00805 (7/13)
- Completion Instructions , F-00805A (7/13)

7/01/13 - 06/30/14

Published policy
through 06/30/14

Prior Authorization / Preferred Drug List (PA/PDL) For Opioid Dependency Agents , F-00081 (7/13)
- Completion Instructions , F-00081A (4/14)

7/01/13 - 06/30/14

Published policy
through 06/30/14

Archived October 1, 2014

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Modafinil^® and Nuvigil^® , F-00079 (12/13)
- Completion Instructions, F-00079A

12/01/13 - 09/30/14

Published policy
through 09/30/14

Prior Authorization Drug Attachment for Sovaldi^TM , F-01247 (07/14)
- Completion Instructions , F-01247A

07/01/14 - 09/30/14

Published policy
through 09/30/14

Prior Authorization / Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents , F-00238 (07/13)
- Completion Instructions , F-00238A

07/01/13 - 09/30/14

Published policy
through 09/30/14

Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs , F-11092 (10/13)
- Completion Instructions , F-11092A

10/01/13 - 09/30/14

Published policy
through 09/30/14

Prior Authorization / Preferred Drug List (PA/PDL) For Multiple Sclerosis (MS) Agents, Immunomodulators , F-00805 (07/14)
- Completion Instructions , F-00805A

07/01/14 - 09/30/14

Published policy
through 09/30/14

Archived December 1, 2014

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Sovaldi , F-01247 (10/14)
- Completion Instructions, F-01247A

10/01/14 - 11/30/14

Published policy
through 11/30/14

Prior Authorization Drug Attachment for Sovaldi Renewal , F-01248 (07/14)
- Completion Instructions, F-01248A

07/01/14 - 11/30/14

Published policy
through 11/30/14

Archived January 1, 2015

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) , F-11083 (07/12)
- Completion Instructions, F-11083A

07/01/12 - 12/31/14

Published policy
through 12/31/14

Prior Authorization Drug Attachment For Anti-Obesity Drugs , F-00163 (10/13)
- Completion Instructions, F-00163A

10/01/13 - 12/31/14

Published policy
through 12/31/14

Prior Authorization Drug Attachment for Modafinil ^® and Nuvigil ^®, F-00079 (10/14)
- Completion Instructions, F-00079A

10/01/14 - 12/31/14

Published policy
through 12/31/14

Archived March 1, 2015

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization / Preferred Drug List (PA/PDL) For Multiple Sclerosis (MS) Agents, Immunomodulators, F-00805 (10/14)

10/01/14 - 02/28/15

Published policy
through 02/28/15

Archived April 1, 2015

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Hepatitis C Protease Inhibitors, F-00583 (07/14)
- Completion Instructions, F-00583A

07/01/14 - 03/31/15

Published policy
through 03/31/15

Prior Authorization Drug Attachment for Stribild, F-01249 (07/14)
- Completion Instructions, F-01249A

07/01/14 - 03/31/15

Published policy
through 03/31/15

Archived July 1, 2015

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids,, F-00194 (07/13)
- Completion Instructions, F-00194A

07/01/13 - 06/30/15

Published policy
through 06/30/15

Prior Authorization / Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents, F-00238 (10/14)
- Completion Instructions, F-00238A

10/01/14 - 06/30/15

Published policy
through 06/30/15

Prior Authorization / Preferred Drug List (PA/PDL) For Multiple Sclerosis (MS) Agents, Immunomodulators, F-00805 (03/15)
- Completion Instructions, F-00805A

03/01/15 - 06/30/15

Published policy
through 06/30/15

Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets, F-11078 (10/11)
- Completion Instructions, F-11078A (07/12)

10/01/11 - 06/30/15

Published policy
through 06/30/15

Archived August 3, 2015

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Hepatitis C Agents, F-01247 (12/14)
- Completion Instructions, F-01247A

12/01/14 - 07/31/15

Published policy
through 07/31/15

Archived January 1, 2016

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger, F-00556 (03/14)
- Completion Instructions, F-00556A (07/15)

03/01/14 - 12/31/15

Published policy
through 12/31/15

Prior Authorization Drug Attachment for Xyrem, F-01430 (01/15)
- Completion Instructions, F-01430A

01/01/15 - 12/31/15

Published policy
through 12/31/15

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease, F-11305 (12/12)
- Completion Instructions, F-11305A (07/15)

12/01/12 - 12/31/15

Published policy
through 12/31/15

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis, F-11306 (01/14)
- Completion Instructions, F-11306A (07/15)

01/01/14 - 12/31/15

Published policy
through 12/31/15

Archived June 1, 2016

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Onabotulinumtoxina (Botox^®) to Treat Chronic Migraines , F-00701 (08/13)
- Completion Instructions, F-00701A

08/01/13 - 05/31/16

Published policy
through 05/31/16

Archived July 1, 2016

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization / Preferred Drug List (PA/PDL) For Opioid Dependency Agents, F-00081 (07/14)
- Completion Instructions, F-00081A

07/01/14 - 06/30/16

Published policy
through 06/30/16

Prior Authorization/Drug Attachment (PA/DGA), F-11049 (10/13)
- Completion Instructions, F-11049A (07/15)

10/01/13 - 06/30/16

Published policy
through 06/30/16

Prior Authorization / Preferred Drug List (PA/PDL) For Multiple Sclerosis (MS) Agents, Immunomodulators, F-00805 (07/15)
- Completion Instructions, F-00805A

07/01/15 - 06/30/16

Published policy
through 06/30/16

Prior Authorization/Preferred Drug List (PA/PDL) for Symlin, F-00080 (10/11)
- Completion Instructions, F-00080A (07/15)

10/01/11 - 06/30/16

Published policy
through 06/30/16

Archived August 1, 2016

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Hepatitis C Agents, F-01247 (08/15)
- Completion Instructions, F-01247A

08/01/15 - 07/31/16

Published policy
through 07/31/16

Prior Authorization Drug Attachment for Hepatitis C Agents Renewal, F-01248 (12/14)
- Completion Instructions, F-01248A

12/01/14 - 07/31/16

Published policy
through 07/31/16

Archived January 1, 2017

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Hepatitis C Agents, F-01247 (08/16)
- Completion Instructions, F-01247A

08/01/16 - 12/31/16

Published policy
through 12/31/16

Prior Authorization Drug Attachment for Modafinil ^® and Nuvigil ^®, F-00079 (01/15)
- Completion Instructions, F-00079A

01/01/15 - 12/31/16

Published policy
through 12/31/16

Prior Authorization Drug Attachment for Xyrem^®, F-01430 (01/16)
- Completion Instructions, F-01430A

01/01/16 - 12/31/16

Published policy
through 12/31/16

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis, F-11304 (12/12)
- Completion Instructions, F-11304A (07,15)

12/01/12 - 12/31/16

Published policy
through 12/31/16

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa, F-01674 (01/16)
- Completion Instructions, F-01674A

01/01/16 - 12/31/16

Published policy
through 12/31/16

Prior Authorization/Preferred Drug List (PA/PDL) for Amphetamine Formulations, F-01672 (01/16)
- Completion Instructions, F-01672A

01/01/16 - 12/31/16

Published policy
through 12/31/16

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis, F-11306 (01/16)
- Completion Instructions, F-11306A

01/01/16 - 12/31/16

Published policy
through 12/31/16

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease, F-11305 (01/16)
- Completion Instructions, F-11305A

01/01/16 - 12/31/16

Published policy
through 12/31/16

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriatic Arthritis, F-11307 (12/12)
- Completion Instructions, F-11307A (07/15)

12/01/12 - 12/31/16

Published policy
through 12/31/16

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule(CAM) Antagonist Drugs for Rheumatoid Arthritis (RA) and Polyarticular Juvenile RA, F-11308 (12/12)
- Completion Instructions, F-11308A (07/15)

12/01/12 - 12/31/16

Published policy
through 12/31/16

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis, F-00694 (12/13)
- Completion Instructions, F-00694A (07/15)

12/01/13 - 12/31/16

Published policy
through 12/31/16

Archived April 3, 2017

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA), F-11083 (01/15)
- Completion Instructions, F-11083A

01/01/15 - 03/31/17

Published policy
through 03/31/17

State Maximum Allowed Cost Drug Pricing Review Request, F-00030 (01/17)
- Completion Instructions, F-00030A

01/01/17 - 03/31/17

Published policy
through 03/31/17

Drug Claims — Compound Drug Claim, F-13073 (07/12)
- Completion Instructions, F-13073A

07/01/12 - 03/31/17

Published policy
through 03/31/17

Drug Claims — Noncompound Drug Claim, F-13072 (10/12)
- Completion Instructions, F-13072A (07/15)

10/01/12 - 03/31/17

Published policy
through 03/31/17

Archived July 3, 2017

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Hepatitis C Agents, F-01247 (01/17)
- Completion Instructions, F-01247A

01/01/17 - 06/30/17

Published policy
through 06/30/17

Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids, F-00162 (07/13)
- Completion Instructions, F-00162A (07/15)

07/01/13 - 06/30/17

Published policy
through 06/30/17

Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids, F-00194 (07/15)
- Completion Instructions, F-00194A

07/01/15 - 06/30/17

Published policy
through 06/30/17

Prior Authorization / Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents, F-00238 (07/15)
- Completion Instructions, F-00238A

07/01/15 - 06/30/17

Published policy
through 06/30/17

Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs, F-11092 (10/14)
- Completion Instructions, F-11092A

10/01/14 - 06/30/17

Published policy
through 06/30/17

Prior Authorization / Preferred Drug List (PA/PDL) For Multiple Sclerosis (MS) Agents, Immunomodulators, F-00805 (07/16)
- Completion Instructions, F-00805A

07/01/16 - 06/30/17

Published policy
through 06/30/17

Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine, F-00081 (07/16)
- Completion Instructions, F-00081A

07/01/16 - 06/30/17

Published policy
through 06/30/17

Archived January 2, 2018

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger, F-00556 (01/16)
- Completion Instructions, F-00556A

01/01/16 - 12/31/17

Published policy
through 12/31/17

Prior Authorization Drug Attachment for Hepatitis C Agents, F-01247 (07/17)
- Completion Instructions, F-01247A

07/01/17 - 12/31/17

Published policy
through 12/31/17

Prior Authorization Drug Attachment for Modafinil and Nuvigil ^®, F-00079 (01/17)
- Completion Instructions, F-00079A

01/01/17 - 12/31/17

Published policy
through 12/31/17

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis, F-11304 (01/17)
- Completion Instructions, F-11304A

01/01/17 - 12/31/17

Published policy
through 12/31/17

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease and Ulcerative Colitis, F-01950 (01/17)
- Completion Instructions, F-01950A

01/01/17 - 12/31/17

Published policy
through 12/31/17

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis, F-11306 (01/17)
- Completion Instructions, F-11306A

01/01/17 - 12/31/17

Published policy
through 12/31/17

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis, F-01951 (01/17)
- Completion Instructions, F-01951A

01/01/17 - 12/31/17

Published policy
through 12/31/17

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis and Neonatal Onset Multisystem Inflammatory Disease (NOMID), F-01952 (01/17)
- Completion Instructions, F-01952A

01/01/17 - 12/31/17

Published policy
through 12/31/17

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis and Neonatal Onset Multisystem Inflammatory Disease (NOMID), F-11077 (12/12)
- Completion Instructions, F-11077A

12/01/12 - 12/31/17

Published policy
through 12/31/17

Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine, F-00081 (07/17)
- Completion Instructions, F-00081A

07/01/17 - 12/31/17

Published policy
through 12/31/17

Archived July 2, 2018

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Modafinil and Nuvigil ^® , F-00079 (01/18)
- Completion Instructions, F-00079A

01/01/18 - 06/30/18

Published policy
through 06/30/18

Prior Authorization / Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents , F-00238 (07/17)
- Completion Instructions, F-00238A

07/01/17 - 06/30/18

Published policy
through 06/30/18

Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs , F-11092 (07/17)
- Completion Instructions, F-11092A

07/01/17 - 06/30/18

Published policy
through 06/30/18

Prior Authorization / Preferred Drug List (PA/PDL) For Multiple Sclerosis (MS) Agents, Immunomodulators , F-00805 (07/17)
- Completion Instructions, F-00805A

07/01/17 - 06/30/18

Published policy
through 06/30/18

Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine , F-00081 (07/17)
- Completion Instructions, F-00081A

07/01/17 - 06/30/18

Published policy
through 06/30/18

Archived September 21, 2018

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs , F-11092 (07/18)
- Completion Instructions, F-11092A

07/01/18 - 09/21/18

Published policy
through 09/21/18

Archived December 7, 2018

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, CGRP Antagonists , F-02371 (09/18)
- Completion Instructions, F-02371A

09/01/18 - 12/07/18

Published policy
through 12/07/18

Archived January 2, 2019

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Xyrem^® , F-01430 (01/17)
- Completion Instructions, F-01430A

01/01/17 - 01/02/19

Published policy
through 01/02/19

Prior Authorization Drug Attachment for Modafinil and Nuvigil , F-00079 (07/18)
- Completion Instructions, F-00079A

07/01/18 - 01/02/19

Published policy
through 01/02/19

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis , F-11304 (01/18)
- Completion Instructions, F-11304A

01/01/18 - 01/02/19

Published policy
through 01/02/19

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease and Ulcerative Colitis , F-01950 (01/18)
- Completion Instructions, F-01950A

01/01/18 - 01/02/19

Published policy
through 01/02/19

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis , F-11306 (01/18)
- Completion Instructions, F-11306A

01/01/18 - 01/02/19

Published policy
through 01/02/19

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis , F-01951 (01/18)
- Completion Instructions, F-01951A

01/01/18 - 01/02/19

Published policy
through 01/02/19

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis, Giant Cell Arteritis, and Neonatal Onset Multisystem Inflammatory Disease (NOMID) , F-01952 (01/18)
- Completion Instructions, F-01952A

01/01/18 - 01/02/19

Published policy
through 01/02/19

Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa , F-01674 (01/17)
- Completion Instructions, F-01674A

01/01/17 - 01/02/19

Published policy
through 01/02/19

Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections , F-00286 (04/14)
- Completion Instructions, F-00286A (07/15)

04/01/14 - 01/02/19

Published policy
through 01/02/19

Archived July 1, 2019

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil Instructions , F-00079 (01/19)
- Completion Instructions, F-00079A

01/01/19 - 06/30/19

Published policy
through 06/30/19

Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine Instructions , F-00081 (07/18)
- Completion Instructions, F-00081A

07/01/18 - 06/30/19

Published policy
through 06/30/19

Prior Authorization Drug Attachment for Hepatitis C Agents Instructions , F-01247 (01/18)
- Completion Instructions, F-01247A

01/01/18 - 06/30/19

Published policy
through 06/30/19

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Giant Cell Arteritis and Neonatal Onset Multisystem Inflammatory Disease (NOMID) Instructions , F-01952 (01/19)
- Completion Instructions, F-01952A

01/01/19 - 06/30/19

Published policy
through 06/30/19

Prior Authorization Drug Attachment for Migraine Agents, Calcitonin Gene-Related Peptide (CGRP) Antagonists Instructions , F-02371 (12/18)
- Completion Instructions, F-02371A

12/01/18 - 06/30/19

Published policy
through 06/30/19

Archived July 1, 2020

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Migraine Agents, Calcitonin Gene-Related Peptide (CGRP) Antagonists , F-02371 (07/19)
- Completion Instructions, F-02371A

07/01/19 - 06/30/20

Published policy
through 06/30/20

Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine , F-00081 (07/19)
- Completion Instructions, F-00081A

07/01/19 - 06/30/20

Published policy
through 06/30/20

Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids , F-00194 (07/17)
- Completion Instructions, F-00194A

07/01/17 - 06/30/20

Published policy
through 06/30/20

Prior Authorization Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents , F-00238 (01/20)
- Completion Instructions, F-00238A

01/01/20 - 06/30/20

Published policy
through 06/30/20

Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Other , F-00280 (07/13)
- Completion Instructions, F-00280A

07/01/13 - 06/30/20

Published policy
through 06/30/20

Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Injectable , F-00622 (06/12)
- Completion Instructions, F-00622A

06/01/12 - 06/30/20

Published policy
through 06/30/20

Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators , F-00805 (07/18)
- Completion Instructions, F-00805A

07/01/18 - 06/30/20

Published policy
through 06/30/20

Prior Authorization Drug Attachment for Hepatitis C Agents , F-01247 (07/19)
- Completion Instructions, F-01247A

07/01/19 - 06/30/20

Published policy
through 06/30/20

Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa , F-02572 (01/20)
- Completion Instructions, F-02572A

01/01/20 - 06/30/20

Published policy
through 06/30/20

Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs , F-11092 (09/18)
- Completion Instructions, F-11092A

09/01/18 - 06/30/20

Published policy
through 06/30/20

Archived September 1, 2020

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Preferred Drug List (PA/PDL) for Belsomra , F-01673 (01/16)
- Completion Instructions, F-01673A

01/01/16 - 08/31/20

Published policy
through 08/31/20

Archived January 4, 2021

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Anti-Obesity Drugs , F-00163 (01/15)
- Completion Instructions, F-00163A

01/01/15 - 12/31/20

Published policy
through 12/31/20

Prior Authorization/Preferred Drug List (PA/PDL) for Expedited Emergency Supply Request , F-00401 (01/20)
- Completion Instructions, F-00401A

01/01/20 - 12/31/20

Published policy
through 12/31/20

Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Immunomodulators , F-00805 (07/20)
- Completion Instructions, F-00805A

07/01/20 - 12/31/20

Published policy
through 12/31/20

Prior Authorization Drug Attachment for Xyrem , F-01430 (01/19)
- Completion Instructions, F-01430A

01/01/19 - 12/31/20

Published policy
through 12/31/20

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease and Ulcerative Colitis , F-01950 (01/19)
- Completion Instructions, F-01950A

01/01/19 - 12/31/20

Published policy
through 12/31/20

Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex , F-02433 (01/19)
- Completion Instructions, F-02433A

01/01/19 - 12/31/20

Published policy
through 12/31/20

Archived April 1, 2021

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Wakix , F-02573 (01/20)
- Completion Instructions, F-02573A

01/01/20 - 03/31/21

Published policy
through 03/31/21

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Giant Cell Arteritis, Neonatal Onset Multisystem Inflammatory Disease (NOMID), and Non-Radiographic Axial Spondyloarthritis (nr-axSpA) , F-01952 (07/19)
- Completion Instructions, F-01952A

07/01/19 - 03/31/21

Published policy
through 03/31/21

Archived July 1, 2021

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Anti-Obesity Drugs , F-000163 (01/21)
- Completion Instructions, F-000163A

01/01/21 - 06/30/21

Published policy
through 06/30/21

Prior Authorization Drug Attachment for Antiemetics, Cannabinoids , F-00194 (07/20)
- Completion Instructions, F-00194A

07/01/20 - 06/30/21

Published policy
through 06/30/21

Prior Authorization Drug Attachment for Headache Agents, Acute Treatment , F-02666 (07/20)
- Completion Instructions, F-02666A

07/01/20 - 06/30/21

Published policy
through 06/30/21

Prior Authorization Drug Attachment for Headache Agents, Preventative Treatment , F-02667 (07/20)
- Completion Instructions, F-02667A

07/01/20 - 06/30/21

Published policy
through 06/30/21

Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine , F-00081 (07/20)
- Completion Instructions, F-00081A

07/01/20 - 06/30/21

Published policy
through 06/30/21

Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request , F-11075 (10/13)
- Completion Instructions, F-11075A

10/01/13 - 06/30/21

Published policy
through 06/30/21

Prior Authorization Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents , F-00238 (07/20)
- Completion Instructions, F-00238A

07/01/20 - 06/30/21

Published policy
through 06/30/21

Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Immunomodulators , F-00805 (01/21)
- Completion Instructions, F-00805A

01/01/21 - 06/30/21

Published policy
through 06/30/21

Prior Authorization / Preferred Drug List (PA/PDL) for Hypoglycemics, Insulin — Long-Acting , F-01749 (07/16)
- Completion Instructions, F-01749A

07/01/16 - 06/30/21

Published policy
through 06/30/21

Archived October 1, 2021

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Synagis , F-00142 (10/14)
- Completion Instructions, F-00142A

10/01/14 - 09/30/21

Published policy
through 09/30/21

Archived December 1, 2021

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Xyrem and Xywav , F-01430 (01/21)
- Completion Instructions, F-01430A

01/01/21 - 11/30/21

Published policy
through 11/30/21

Archived January 3, 2022

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis , F-11304 (01/19)
- Completion Instructions, F-11304A

01/01/19 - 12/31/21

Published policy
through 12/31/21

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis , F-01950 (01/21)
- Completion Instructions, F-01950A

01/01/21 - 12/31/21

Published policy
through 12/31/21

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Deficiency of Interleukin-1 Receptor Antagonist (DIRA), Giant Cell Arteritis, Neonatal Onset Multisystem Inflammatory Disease (NOMID), and Non-Radiographic Axial Spondyloarthritis (nr-axSpA , F-01952 (04/21)
- Completion Instructions, F-01952A

04/01/21 - 12/31/21

Published policy
through 12/31/21

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis , F-11306 (01/19)
- Completion Instructions, F-11306A

01/01/19 - 12/31/21

Published policy
through 12/31/21

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis , F-01951 (01/20)
- Completion Instructions, F-01951A

01/01/20 - 12/31/21

Published policy
through 12/31/21

Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa , F-02572 (07/20)
- Completion Instructions, F-02572A

07/01/20 - 12/31/21

Published policy
through 12/31/21

Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants , F-01672 (01/17)
- Completion Instructions, F-01672A

01/01/17 - 12/31/21

Published policy
through 12/31/21

Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) , F-11077 (01/18)
- Completion Instructions, F-11077A

01/01/18 - 12/31/21

Published policy
through 12/31/21

Archived April 1, 2022

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis , F-11304 (01/22)
- Completion Instructions, F-11304A

01/01/22 - 3/31/22

Published policy
through 3/31/22

Prior Authorization/Preferred Drug List (PA/PDL) for Belsomra and Dayvigo , F-01673 (9/20)
- Completion Instructions, F-01673A

09/01/20 - 3/31/22

Published policy
through 3/31/22

Archived July 1, 2022

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis , F-01951 (01/22)
- Completion Instructions, F-01951A

01/01/22 - 06/30/22

Published policy
through 06/30/22

Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets , F-00433 (07/13)
- Completion Instructions, F-00433A

07/01/13 - 6/30/22

Published policy
through 6/30/22

Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents , F-00805 (07/21)
- Completion Instructions, F-00805A

07/01/21 - 6/30/22

Published policy
through 6/30/22

Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors , F-02505 (07/19)
- Completion Instructions, F-02505A

07/01/19 - 6/30/22

Published policy
through 6/30/22

Prior Authorization Drug Attachment for Headache Agents, Acute Treatment , F-02666 (07/21)
- Completion Instructions, F-02666A

07/01/21 - 6/30/22

Published policy
through 6/30/22

Prior Authorization Drug Attachment for Headache Agents, Preventative Treatment , F-02667 (07/21)
- Completion Instructions, F-02667A

07/01/21 - 6/30/22

Published policy
through 6/30/22

Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets , F-11078 (07/15)
- Completion Instructions, F-11078A

07/01/15 - 6/30/22

Published policy
through 6/30/22

Prior Authorization/"J" Code Attachment (PA/JCA) , F-11034 (07/12)
- Completion Instructions, F-11034A

07/01/12 - 6/30/22

Published policy
through 6/30/22

Archived September 16, 2022

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Anti-Obesity Drugs , F-00163 (07/21)
- Completion Instructions, F-00163A

07/01/21 - 09/16/22

Published policy
through 09/16/22

Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura , F-02572 (01/22)
- Completion Instructions, F-02572A

01/01/22 - 09/16/22

Published policy
through 09/16/22

Archived January 3, 2023

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis , F-02572 (09/22)
- Completion Instructions, F-02572A

09/01/22 - 12/31/22

Published policy
through 12/31/22

Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex , F-02433 (04/22)
- Completion Instructions, F-02433A

04/01/22 - 12/31/22

Published policy
through 12/31/22

Archived April 3, 2023

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Anti-Obesity Drugs , F-00163 (09/22)
- Completion Instructions, F-00163A

09/01/22 - 03/31/23

Published policy
through 03/31/23

Archived May 1, 2023

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease and Ulcerative Colitis , F-01950 (01/22)
- Completion Instructions, F-01950A

01/01/22 - 04/30/23

Published policy
through 04/30/23

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis , F-01951 (07/22)
- Completion Instructions, F-01951A

07/01/22 - 04/30/23

Published policy
through 04/30/23

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis , F-11304 (04/22)
- Completion Instructions, F-11304A

04/01/22 - 04/30/23

Published policy
through 04/30/23

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis , F-11306 (01/22)
- Completion Instructions, F-11306A

01/01/22 - 04/30/23

Published policy
through 04/30/23

Archived July 3, 2023

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents , F-00238 (07/21)
- Completion Instructions, F-00238A

07/01/21 - 06/30/23

Published policy
through 06/30/23

Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents , F-00805 (07/22)
- Completion Instructions, F-00805A

07/01/22 - 06/30/23

Published policy
through 06/30/23

Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids , F-00162 (05/20)
- Completion Instructions, F-00162A

05/01/20 - 06/30/23

Published policy
through 06/30/23

Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request , F-11075 (07/21)
- Completion Instructions, F-11075A

07/01/21 - 06/30/23

Published policy
through 06/30/23

Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs , F-11092 (07/20)
- Completion Instructions, F-11092A

07/01/20 - 06/30/23

Published policy
through 06/30/23

Archived October 2, 2023

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Synagis, F-00142 (10/21)
- Completion Instructions, F-00142A

10/01/21 - 09/30/23

Published policy
through 09/30/23

Archived January 2, 2024

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Drug Attachment (PA/DGA), F-11049 (07/16)
- Completion Instructions, F-11049A

07/01/16 - 12/31/23

Published policy
through 12/31/23

Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine, F-00081 (07/21)
- Completion Instructions, F-00081A

07/01/21 - 12/31/23

Published policy
through 12/31/23

Archived July 1, 2024

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine, F-00081 (01/24)
- Completion Instructions, F-00081A

01/01/24 - 06/30/24

Published policy
through 06/30/24

Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids, F-00162 (07/23)
- Completion Instructions, F-00162A

07/01/23 - 06/30/24

Published policy
through 06/30/24

Prior Authorization Drug Attachment for Anti-Obesity Drugs, F-00163 (04/23)
- Completion Instructions, F-00163A

04/01/23 - 06/30/24

Published policy
through 06/30/24

Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents, F-00238 (07/23)
- Completion Instructions, F-00238A

07/01/23 - 06/30/24

Published policy
through 06/30/24

Prior Authorization Drug Attachment for Hypoglycemics, Insulins Long-Acting, F-01749 (07/21)
- Completion Instructions, F-01749A

07/01/21 - 06/30/24

Published policy
through 06/30/24

Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors, F-02505 (07/22)
- Completion Instructions, F-02505A

07/01/22 - 06/30/24

Published policy
through 06/30/24

Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs, F-11092 (07/23)
- Completion Instructions, F-11092A

07/01/23 - 06/30/24

Published policy
through 06/30/24

Archived October 1, 2024

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis, F-02572 (01/23)
- Completion Instructions, F-02572A

01/01/23 - 09/30/24

Published policy
through 09/30/24

Prior Authorization Drug Attachment for Wakix, F-02573 (04/21)
- Completion Instructions, F-02573A

04/01/21 - 09/30/24

Published policy
through 09/30/24

Archived January 2, 2025

Form Name

Effective Dates

Associated Online
Handbook Archive
(if applicable)

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease and Ulcerative Colitis, F-01950 (05/23)
- Completion Instructions, F-01950A

05/01/23 - 12/31/24

Published policy
through 12/31/24

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis, F-01951 (05/23)
- Completion Instructions, F-01951A

05/01/23 - 12/31/24

Published policy
through 12/31/24

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Deficiency of Interleukin-1 Receptor Antagonist (DIRA), Giant Cell Arteritis, Neonatal Onset Multisystem Inflammatory Disease (NOMID), and Non-Radiographic Axial Spondyloarthritis (nr-axSpA), F-01952 (01/22)
- Completion Instructions, F-01952A

01/01/22 - 12/31/24

Published policy
through 12/31/24

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa, F-03174 (07/23)
- Completion Instructions, F-03174A

07/01/23 - 12/31/24

Published policy
through 12/31/24

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis, F-03224 (10/23)
- Completion Instructions, F-03224A

10/01/23 - 12/31/24

Published policy
through 12/31/24

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis, F-11304 (05/23)
- Completion Instructions, F-11304A

05/01/23 - 12/31/24

Published policy
through 12/31/24

Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis, F-11306 (05/23)
- Completion Instructions, F-11306A

05/01/23 - 12/31/24

Published policy
through 12/31/24

Prior Authorization/Preferred Drug List (PA/PDL) for Immunomodulators, Atopic Dermatitis – Topical, F-02572 (10/24)
- Completion Instructions, F-02572A

10/01/24 - 12/31/24

Published policy
through 12/31/24

Prior Authorization/Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents, F-00281 (07/13)
- Completion Instructions, F-00281A

07/01/13 - 12/31/24

Published policy
through 12/31/24

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