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Prior Authorization Forms Forms

Form name
Actemra – English
180 KB April 21, 2021
Amgevita-English
159 KB April 21, 2021
Avsola-English
160 KB April 21, 2021
Cialis and Generics – English
215 KB April 26, 2021
Hadlima – English
159 KB April 21, 2021
Hulio – English
160 KB April 21, 2021
Hyrimoz – English
160 KB April 21, 2021
Idacio – English
160 KB April 21, 2021
Rinvoq – English
159 KB April 21, 2021
Riximyo – English
159 KB April 21, 2021
Ruxience – English
159 KB April 21, 2021
Siliq – English
159 KB April 21, 2021
Skyrizi – English
159 KB April 21, 2021
Staxyn – English
159 KB April 21, 2021
Truxima – English
159 KB April 21, 2021
Viagra and Generics – English
159 KB April 26, 2021
Actemra – French
132 KB October 8, 2020
Adcirca – English
180 KB April 21, 2021
Adcirca – French
131 KB October 8, 2020
Aubagio – English
188 KB April 21, 2021
Aubagio – French
130 KB October 8, 2020
Benlysta – English
215 KB April 21, 2021
Benlysta – French
122 KB October 8, 2020
Botox – English
216 KB April 21, 2021
Botox – French
193 KB October 8, 2020
Brenzys – English
188 KB April 21, 2021
Brenzys – French
232 KB October 8, 2020
Cialis et génériques – French
204 KB April 27, 2021
Levitra – English
159 KB April 21, 2021
Cialis for Benign Prostatic Hyperplasia (BPH) – English
219 KB October 8, 2020
Cialis des Symptomes de Lhyperplasie Benigne de la Prostate (HBP) – French
129 KB October 8, 2020
Cimzia – English
219 KB April 21, 2021
Cimzia – French
133 KB October 8, 2020
Contrave – English
216 KB April 21, 2021
Contrave – French
129 KB October 8, 2020
Cosentyx – English
219 KB April 21, 2021
Cosentyx – French
264 KB October 8, 2020
Dupixent – English
216 KB April 21, 2021
Dupixent – French
118 KB October 8, 2020
Dysport – English
219 KB April 21, 2021
Dysport – French
185 KB October 8, 2020
Enbrel – English
160 KB April 21, 2021
Enbrel – French
134 KB October 8, 2020
Entyvio – English
190 KB April 21, 2021
Entyvio – French
234 KB October 8, 2020
Erelzi – English
160 KB April 21, 2021
Erelzi – French
132 KB October 8, 2020
Fampyra – English
159 KB April 21, 2021
Fampyra – French
85 KB October 8, 2020
Gilenya – English
193 KB April 21, 2021
Gilenya – French
131 KB October 7, 2020
Humira – English
160 KB April 21, 2021
Humira – French
186 KB October 7, 2020
Inflectra – English
159 KB April 21, 2021
Inflectra – French
200 KB October 7, 2020
Jakavi – English
159 KB April 21, 2021
Jakavi – French
172 KB October 7, 2020
Kevzara – English
160 KB April 21, 2021
Kevzara – French
117 KB October 7, 2020
Kineret – English
159 KB April 21, 2021
Kineret – French
132 KB October 7, 2020
Lemtrada – English
159 KB April 21, 2021
Lemtrada – French
117 KB October 7, 2020
Mavenclad – English
159 KB April 21, 2021
Mavenclad – French
169 KB October 7, 2020
Nucala – English
159 KB April 21, 2021
Nucala – French
118 KB October 7, 2020
Olumiant – English
159 KB April 21, 2021
Olumiant – French
129 KB October 7, 2020
Orencia – English
159 KB April 21, 2021
Orencia – French
130 KB October 7, 2020
Otezla – English
159 KB April 21, 2021
Otezla – French
190 KB October 7, 2020
Remicade – English
159 KB April 21, 2021
Remicade – French
174 KB October 7, 2020
Renflexis – English
159 KB April 21, 2021
Renflexis – French
124 KB October 7, 2020
Repatha – English
159 KB April 21, 2021
Repatha – French
131 KB October 7, 2020
Revatio – English
160 KB April 21, 2021
Revatio – French
137 KB October 7, 2020
Rituxan – English
159 KB April 21, 2021
Rituxan – French
129 KB October 7, 2020
Sativex – English
160 KB April 21, 2021
Sativex – French
131 KB October 7, 2020
Saxenda – English
160 KB April 21, 2021
Saxenda – French
131 KB October 7, 2020
Simponi – English
159 KB April 21, 2021
Simponi – French
159 KB October 7, 2020
Stelara – English
160 KB April 21, 2021
Stelara – French
133 KB October 7, 2020
Taltz – English
159 KB April 21, 2021
Taltz – French
83 KB October 7, 2020
Thyrogen – English
160 KB April 21, 2021
Thyrogen – French
131 KB October 7, 2020
Tremfya – English
159 KB April 21, 2021
Tremfya French
157 KB October 7, 2020
Xeljanz – English
159 KB April 21, 2021
Xeljanz – French
130 KB October 7, 2020
Xenical – English
159 KB April 21, 2021
Xenical – French
131 KB October 7, 2020
Xeomin – English
160 KB April 21, 2021
Xeomin – French
131 KB October 7, 2020
Xolair – French
130 KB October 5, 2020
Xolair – English
160 KB April 21, 2021