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Anti-allergens, Oral (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Grastek, Odactra, Oralair, Ragwitek,
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Anti-allergens, Oral - Palforzia (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Palforzia,
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Antiemetic/Antivertigo Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Marinol, dronabinol, Syndros, Ondansetron ,
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Antifungals, Oral (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Ancobon, flucytosine, clotrimazole, Cresemba, Diflucan, griseofulvin, ketoconazole, Lamisil, Noxafil, posaconazole, Sporanox, itraconazole, Tolsura, Vfend, voriconazole,
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Antifungals, Topical (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Ciclopirox, Penlac, CNL-8, Efinaconazole, Jublia, Lulizonazole, Luzu, Tavaborole, Kerydin,
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Antimigraine Agents, Others (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Ubrelvy, Reyvow, Trudhesa, Zavzpret,
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Antimigraine Agents, Vyepti (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Vyepti,
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Antipsychotics in Children Younger Than 18 Years Old (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Abilify, aripiprazole, Clozaril, clozapine, Versacloz, Geodon, ziprasidone, Latuda, lurasidone, Zyprexa, olanzapine, Symbyax, olanzapine/fluoxetine, risperidone, Risperdal, Seroquel, quetiapine, Fanapt, Invega, paliperidone, Rexulti, Saphris, asenapine, Caplyta, Aristada, Rykindo, Perseris, perphenazine/amitriptyline, chlorpromazine, fluphenazine, haloperidol, Haldol, loxapine, perphenazine, trifluoperazine, thiothixene, thioridazine, molindone, pimozide, Secuado, Lybalvi, Adasuve, Uzedy, Erzofri, Opipza, Cobenfy, Vraylar ,
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Briumvi (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Briumvi,
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Cinqair (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Cinqair,
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Colony Stimulating Factors, Non-Preferred (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
,
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Cytokine and CAM Antagonists and Related Agents (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Tremfya, Stelara, Otulfi, Pyzchiva, Selarsdi, Steqeyma, Yesintek, Wezlana, Ustekinumab, Rinvoq, Methotrexate, Jylamvo, Omvoh, Enbrel, Kevzara, Actemra, Tyenne, Tofidence, Entyvio, Xeljanz, Xeljanz XR, Arcalyst, Taltz, Simponi, Bimzelx, Skyrizi, Humira, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry, Simlandi, Adalimumab, Cimzia, Spevigo, Otezla, Velsipity, Cosentyx, Ilaris, Kineret, Orencia, Infliximab, Remicade, Avsola, Inflectra, Renflexis, Zymfentra, Cibinqo, Otrexup, Rasuvo, Reditrex, Xatmep, Ilumya, Siliq, Enspryng, Olumiant ,
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Duchenne Muscular Dystrophy (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Amondys 45, Exondys 51, Vyondys 53, Viltepso, Emflaza, delflazacort, Agamree, Duvyzat,
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Dupixent (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Dupixent,
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Fasenra (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Fasenra,
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Forteo, Tymlos, Teriparatide (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Forteo, Tymlos, Teriparatide,
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GI Motility, Chronic (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Amitiza, Linzess, Lubiprostone, Movantik, Alosetron, Lotronex, Motegrity, Relistor, Symproic, Trulance, Viberzi,
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GLP-1 Receptor Agonists for Cardiovascular Risk Reduction (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Wegovy,
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Growth Hormone (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Genotropin, Saizen, Saizen Prep, Humatrope, Norditropin Flexpro, Nutropin AQ, Omnitrope, Zomacton, Zorbitive, Serostim, Skytrofa,
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Hepatitis C Antivirals, Non-Preferred (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Epclusa, Harvoni, Ledipasvir/sofosbuvir, Sovaldi, Vosevi, Viekira Pak, Zepatier, Pegasys,
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Hereditary Angioedema (HAE) Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Cinryze, Berinert, Icatibant, Sajazir, Kalbitor, Firazyr, Orladeyo, Ruconest, Takhzyro, Haegarda,
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Incretin Mimetics, Non-Preferred (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Byetta, Trulicity, Victoza, liraglutide, Ozempic, Mounjaro, Rybelsus, Xultophy, Soliqua,
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Juxtapid (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Juxtapid,
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Lipotropics, Other (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Leqvio, Praluent, Repatha, Nexletol, Nexlizet,
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Multiple Sclerosis (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Mavenclad, Mayzent, Ponvory, Zeposia,
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Narcolepsy Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Armodafinil, Modafinil, Nuvigil, Provigil, Sunosi, Wakix,
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Nucala (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Nucala,
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Ocrevus (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Ocrevus,
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Oral Buprenorphine Products (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Suboxone, buprenorphine/naloxone, Zubsolv,
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Proton Pump Inhibitors (PPIs) (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Aciphex, rabeprazole, Dexilant, dexlansoprazole, esomeprazole, Nexium, Prevacid, lansoprazole, Prilosec, omeprazole, Protonix, pantoprazole, Zegerid, omeprazole-sodium bicarbonate, Konvomep,
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Short and Long-acting Opioids (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Actiq, fentanyl, Fentora, butorphanol, Apadaz, benzhydrocodone-acetaminophen, Trezix, acetaminophen-caffeine-dihydrocodeine, acetaminophen-codeine, codeine, Fioricet-Codeine, butalbital-acetaminophen-caffeine-codeine, Ascomp-codeine, butalbital-aspirin-caffeine-codeine, morphine sulfate, Lortab, hydrocodone-acetaminophen, Xodol, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Dilaudid, hydromorphone, levorphanol, meperidine, oxycodone, Roxicodone, Oxaydo, Nalocet, Endocet, Prolate, Percocet, oxycodone-acetaminophen, oxymorphone, pentazocine-naloxone, Nucynta, belladonna alk-opium, Opium, Ultram, tramadol, Ultracet, tramadol-acetaminophen, Synapryn, Qdolo, Seglentis, nalbuphine, Roxybond, morphine ER, Belbuca, Butrans, buprenorphine patch, Conzip, tramadol ER, hydromorphone ER, fentanyl patch, Hysingla ER, hydrocodone ER, MS Contin, Nucynta ER, Oxycontin, oxycodone ER, oxymorphone ER, Xtampza ER,
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Sickle Cell Disease Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Adakveo, Siklos, Glutamine, Droxia, Endari,
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Stimulants/ADHD Medications for Children Less than FDA Indicated Age and Adults (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Adzenys XR-ODT, Dyanavel XR, Evekeo, amphetamine, Evekeo ODT, Mydayis, Adderall XR, amphetamine/dextroamphetamine, Adderall, Zenzedi, dextroamphetamine, Dexedrine, dextroamphetamine ER, Procentra, Vyvanse, lisdexamfetamine, Desoxyn, methamphetamine, Ritalin, methylphenidate, Methylin, Quillivant XR, methylphenidate ER, Concerta, Metadate CD, Jornay PM, Ritalin LA, Cotempla XR-ODT, Quillichew ER, Daytrana, Focalin XR, dexmethylphenidate ER, Focalin, dexmethylphenidate, Relexxii, Azstarys, Xelstrym, Aptensio XR,
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Tezspire (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Tezspire,
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Tysabri (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Tysabri,
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Weight-Loss Management (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
phentermine, Adipex-P, Lomaira, phendimetrazine, phendimetrazine ER, Benzphetamine, diethylpropion, diethylpropion ER, Saxenda, Zepbound, Wegovy, Xenical, Orlistat, Alli, Imcivree ,
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Xolair (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
Xolair,