Drug-Specific Prior Authorizations
Medicaid and CHIP

Drugs listed on this page require prior authorization from Medicaid and CHIP.

If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Using the appropriate form will help to ensure that we have the information necessary to make a decision about your request.

Please note that there are different prior authorization forms for Medicare and Individual and Family Plans. To access those forms, visit the Medicare and IFP pages: