Pharmacy
For our Medicaid Formularies, please click on the appropriate tab. You will need Adobe Reader to view these files. To save it to your computer, right-click and select "Save Target As..." (or most similar option depending on your browser). If you are having problems viewing the documents, please try installing the latest version of Adobe Reader.
Documents on this page are appropriate for Medicaid.
Prior Authorization Forms
| Title | Last Updated |
|---|---|
| Medication Prior Authorization Form (to be completed by the prescribing physician) MEDICAID ONLY | February 2012 |
| Medication Prior Authorization Fuzeon MEDICAID ONLY | February 2012 |
| Medication Prior Authorization HIV-HEP-B Diagnosis Verification MEDICAID ONLY | February 2012 |
| Medication Prior Authorization Selzentry Maraviroc MEDICAID ONLY | February 2012 |
| Medication Prior Authorization Serostim | February 2012 |
| Synagis Request MEDICAID ONLY | February 2012 |
Medicaid Formularies
| Title | Last Updated |
|---|---|
| Medicaid Preferred Formulary MEDICAID ONLY | January 2012 |
| Medicaid Prior Authorization & Step Therapy MEDICAID ONLY | December 2011 |
| $25 Over-the-Counter Coverage MEDICAID ONLY | March 2011 |