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Prior Authorization Request Forms
Title
A Universal Form - Can't find the form you need?
Ace Inhibitors
Ace/Calcium Channel Blockers
Actiq
Advair
Age Override Form
Aldara
Alzheimer's Agents
Amitiza
Androgenic Agents
Angiotensin Modulators-Channel Blockers
Anti Parkinson Agents
Antiacne Agents, Topical
Antibiotics, Otic (For The Ear)
Antidepressants, Other
Antidepressants, SSRI
Antiemetics. Oral
Antiepileptic Agents for Pain and Mood Disorderss
Antiepileptics
Antifungals for Onychomycosis, Oral
Antifungals, Topical
Antihistamine, Minimally Sedating
ARB
Benzaclin/DUAC
Benzamyacin
Beta Blocker
Beta-2 Agonists, Inhaled
Bone Resorption & Suppression
Brand Name
Byetta
Carbamazepine, Extended Release
Cephalosporins and Related Antibiotics, Oral
Clindamycin Pledgetts
COX-2
Cymbalta
Emend
Emsam
EPSDT
Erythromycin Pledgetts
Erythropoiesis Stimulating Proteins
Fentora
Fluoroquinolones, Oral
Fluoroquinolones, Otic (for the Ear)
Fluroquinolone Ophthalmics
Glucocorticoids, Inhaled
Growth Hormone
Hepatitis C Agents-Interferons
Hepatitis C Agents-Ribavirin
Insulins (Short Acting Only)
Intranasal Rhinitis Agents
Klonopin Wafers
Leukotrienes
Lipotropics, Other
Macrolides-Ketolides, Oral
Marinol
MedWatch Form (Electronic Submission)
MedWatch Form (PDF)
Narcotics Analgesic Long Acting
Narcotics Short Acting
NSAIDS
Ophthalmics for Allergic Conjunctivitis
Platelet Aggregation Inhibitors
Proton Pump Inhibitors (PPI)
Prozac Weekly
Quantity Override
Regranex
Retinoids, Oral
Return Drug Form
Sedative Hypnotics
Skeletal Muscle Relaxants
Statins
Stimulants
Strattera
Symlin
Synagis
Tekturna
Triptan
Urinary Incontinence
Vytorin
Xanax XR
Xenical
Xolair
Zetia
Prior Authorization Criteria

This information is now included on PA forms and/or the Preferred Drug List. It will no longer be duplicated here. For questions, please contact Idaho Medicaid Pharmacy at 364-1829 or 1-866-827-9967.

Idaho Department of Health and Welfare

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