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Rhode Island 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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  • Antipsychotics (Rhode Island) Prior Authorization Form - Community Plan

    Last Published 02.24.2022

    Abilify Maintena, Abilify MyCite, Abilify, aripiprazole ODT, aripiprazole oral solution, aripiprazole, Aristada, Caplyta, clozapine, Clozaril, Fanapt, Geodon, Invega Sustenna, Invega, Invega Trinza, Latuda, olanzapine ODT, olanzapine, paliperidone ER, Perseris, quetiapine ER, quetiapine, Rexulti, Risperdal Consta, Risperdal oral solution, Risperdal, risperidone ODT, risperidone oral solution, risperidone, Saphris, Secuado, Seroquel XR, Seroquel, Versacloz, Vraylar, ziprasidone, Zyprexa Zydis, Zyprexa,
  • Cough and Cold, Opiate Combination (Rhode Island) Prior Authorization Form - Community Plan

    Last Published 02.24.2022

    Hydromet, hydrocodone-homatropine, Z-Tuss AC, Tuzistra XR, Tussicaps, hydrocodone-chlorpheniramine, M-END PE, Poly-Tussin AC, Capcof, Pro-Red AC, Histex-AC, Maxi-Tuss, promethazine w/codeine, Promethazine VC/codeine, promethazine-phenylephrine-codeine, Rydex, Mar-Cof BP, Mar-Cof GG, Ninjacof-XG, Coditussin AC, Coditussin DAC, guaifenesin-codeine, Lortuss EX, pseudoephedrine w/codeine-guaifenesin, Tuxarin ER, Guiatuss AC, Lortuss, Tusnel C, Virtussin,
  • Dry Eye Disease (Rhode Island) Prior Authorization Form - Community Plan

    Last Published 02.24.2022

    Cequa, Restasis, Restasis Multidose, Xiidra,
  • GLP-1 Agonists (Rhode Island) Prior Authorization Form - Community Plan

    Last Published 02.24.2022

    Adlyxin, Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza,
  • Hepatitis C Medications (Rhode Island) Prior Authorization Form - Community Plan

    Last Published 02.24.2022

    Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier,
  • Opioid Products (Rhode Island) Prior Authorization Form - Community Plan

    Last Published 02.24.2022

    Morphine ER, Xtampza, tramadol ER, Hydromorphone ER, MS Contin, fentanyl transdermal, Zohydro ER, hydrocodone ER, Oxymorphone ER, Methadose, Methadone, Hysingla ER, Oxycontin, oxycodone CR, Nucynta ER, Duragesic, 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 ,
  • SGLT-2 Inhibitors (Rhode Island) Prior Authorization Form - Community Plan

    Last Published 02.24.2022

    Steglatro, Segluromet, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, Synjardy XR, Farxiga, Xigduo XR,
  • Suboxone / Subutex (Rhode Island) Prior Authorization Form - Community Plan

    Last Published 02.24.2022

    Suboxone sublingual film, buprenorphine sublingual tablet, Zubsolv, Bunavail, buprenorphine/naloxone,