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Arizona Community Plan Pharmacy Prior Authorization Forms

To simplify your experience with prior authorization and save time, please submit your prior authorization request through the following online portals:

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Electronic Prior Authorization (ePA)

Submit an ePA using CoverMyMeds

Select Electronic Prior Authorization (ePA)
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Electronic prior authorization (ePA)

Submit an ePA using SureScripts

Select Electronic prior authorization (ePA)

Otherwise, you can submit requests by completing and faxing the applicable form below. You can search for a drug specific form by entering the requested drug in the search box below. If your search does not yield a result, please use this Prior Authorization Request form.

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ADHD Products (Arizona) Prior Authorization Form - Community Plan

Last Published 02.22.2022

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

Adderall, Adderall XR, Adhansia XR, Adzenys ER, Adzenys XR, amphetamine, amphetamine/dextroamphetamine, amphetamine/dextroamphetamine ER, Aptensio XR, atomoxetine, Catapres, clonidine, clonidine ER, Concerta, Cotempla XR, Daytrana, Desoxyn, Dexedrine, dexmethylphenidate, dexmethylphenidate ER, dextroamphetamine, dextroamphetamine ER, Dyanavel, Evekeo, Evekeo ODT, Focalin, Focalin XR, guanfacine ER, guanfacine, Intuniv, Jornay PM, Kapvay, Metadate ER, methamphetamine, Methylin, methylphenidate, methylphenidate ER, Mydayis, Procentra, Quillichew, Quillivant, Ritalin, Ritalin LA, Strattera, Vyvanse, Zenzedi ,

Antipsychotics (Arizona) Prior Authorization Form - Community Plan

Last Published 02.21.2022

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

haloperidol, loxapine, perphenazine, thioridazine, thiothixene, pimozide, fluphenazine, trifluoperazine, chlorpromazine, lithium carbonate, lithium carbonate ER, aripiprazole, ziprasidone, Latuda, risperidone, risperidone ODT, quetiapine, olanzapine, Invega Sustenna, Risperdal Consta, Abilify Maintena, Invega Trinza, Aristada, Aristada Initio, Perseris, Abilify, Abilify Mycite, Clozaril, clozapine, Geodon, Haldol decanoate, Lithobid, Orap, Risperdal, Seroquel, Zyprexa, Zyprexa Zydis, perphenazine-amitriptyline, molindone, aripiprazole ODT, aripiprazole, Caplyta, Invega, paliperidone, Fanapt, Seroquel XR, quetiapine ER, Rexulti, Saphris, Secuado, Symbyax, fluoxetine-olanzapine, Versacloz, Vraylar, Zyprexa Relprevv,

Arizona Reinsurable Drug Program (Arizona) Prior Authorization Form - Community Plan

Last Published 02.22.2022

*** These products are part of the Arizona Reinsurable Drug List and are a pharmacy benefit.*** 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

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Dupixent (AZ, HI, MD, NJ, NY-CHIP, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan

Last Published 04.01.2023

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, 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,

GLP-1 Agonists (Arizona) Prior Authorization Form - Community Plan

Last Published 11.01.2023

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

"Byetta, Victoza, Bydureon, Trulicity, Adlyxin, Ozempic , Bydureon BCise, Rybelsus ",

Medicaid Synagis Authorization Request Form - Community Plan

Last Published 04.01.2023

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. Excludes: New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me

Synagis,

Opioid Products (Arizona) Prior Authorization Form - Community Plan

Last Published 01.06.2023

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

"Morphine ER, Xtampza, tramadol ER, Hydromorphone ER, MS Contin, fentanyl transdermal, hydrocodone ER, Oxymorphone ER, Methadose, Methadone, Hysingla ER, Oxycontin, oxycodone CR, Nucynta ER, Conzip, Butorphanol, carisoprodol-aspirin-codeine, codeine, acetaminophen-codeine, butalbital-acetaminophen-caffeine-codeine, Fioricet-codeine, butalbital-aspirin-caffeine-codeine, morphine, hydrocodone-acetaminophen, Lortab, Xodol, hydrocodone-ibuprofen, Dilaudid, hydromorphone, oxycodone, Roxicodone, Oxaydo, oxycodone-acetaminophen, Percocet, Prolate, Nalocet, Endocet, oxycodone-aspirin, oxymorphone, pentazocine-naloxone, Ultram, Synapryn, tramadol, Ultracet, tramadol-acetaminophen, Qdolo, Nucynta, meperidine, levorphanol, acetaminophen-caffeine-dihydrocodeine, Trezix, belladonna alkaloids-opium, opium, Apadaz, benzhydrocodone-acetaminophen, Ascomp/codeine, Seglentis, Roxybond",