Drug Specific Prior Authorizations 2024 (Medicaid/CHIP)
Drugs listed on this page require prior authorization from Health Partners (Medicaid) and KidzPartners (CHIP).
Please note that there are different prior authorization forms for Jefferson Health Plans' Medicare and ACA plans. Forms are also sent to different fax numbers.
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 assure that we have the information necessary to make a decision about your request.
2024 Non-PDL Prior Authorizations:
2024 PDL Prior Authorizations: