Pharmacy Services Fax Forms | Department of Human Services | Commonwealth of Pennsylvania

Pharmacy Services Fax Forms | Department of Human Services | Commonwealth of Pennsylvania
Pharmacy Services
Fee-for-Service Pharmacy Prior Authorization Fax Forms
​​Statewide PDL Drugs/Drug Classes Fax Forms*
NOTE: Please use the
Non-Preferred Medication Form
for drugs included on the Statewide PDL that do not have a corresponding drug-specific or PDL class-specific form in the list below.
Acne Agents, Oral Form
Acne Agents, Topical Form
Analgesics, Non-Opioid Barbiturate Combinations Form
Analgesics, Acute Pain Agents Form
Analgesics, Opioids Long-Acting Form
Analgesics, Opioids Short-Acting Form
Androgenic Agents Form
Antibiotics, GI and Related Agents Form
Antidepressants, Other
Antifibrotic Respiratory Agents
Antihemophilia Agents Form
Antihyperuricemics - Krystexxa Form
Antipsoriatrics, Topical Form
Antipsychotics Form
Antivirals, CMV Form
Benzodiazepines Form
Blood Glucose Meters and Test Strips Form
Bone Density Regulators Form
Botulinum Toxins Form
Colony Stimulating Factors Form
Continuous Glucose Monitoring Products Form
COPD Agents - Daliresp Form
Cytokine and CAM Antagonists Form
Dupixent Form
Enzyme Replacements, Gaucher Disease Form
Erythropoiesis Stimulating Agents Form
Estrogens Form
GI Motility, Chronic
GLP-1 Receptor Agonists Form
Glucocorticoids, Oral Form
Growth Hormones Form
Hepatic and Biliary Agents Form
Hepatitis C Agents Form
Hereditary Angioedema Agents Form
Hypoglycemics, DPP-4 Inhibitors Form
Immunomodulators, Dermatologics
Immunosuppressives, Oral - Lupkynis Form
Intra-Articular Hyaluronates Form
Iron Chelating Agents Form
Lipotropics, Other Form
Macular Degeneration Agents Form
Migraine Acute Treatment Agents Form
Migraine Prevention Agents Form
Monoclonal Antibodies - Anti-IL, Anti-IgE, Anti-TSLP Form
Multiple Sclerosis Form
Natalizumb Form
NSAIDs - Ketorolac Form
Obesity Treatment Agents Form
Oncology Agents, Oral Form
Opioid Use Disorder Treatments Form
Pituitary Suppressive Agents, LHRH Form
Potassium Removing Agents Form
Proton Pump Inhibitors < 6 Years of Age Form
Pulmonary Hypertension Agents, Oral and Inhaled Form
Sickle Cell Anemia Agents Form
Stimulants and Related Agents Form
Stimulants and Related Agents - Provigil, Nuvigil, Sunosi, and Wakix Form
Thalidomide and Derivatives Form
Thrombopoietics Form
Ulcerative Colitis Agents Form
Urea Cycle Disorder Agents Form
VMAT2 Inhibitors Form
Fee-for-Service Non-PDL Drugs/Drug Classes Fax Forms
Abecma Form
Adstiladrin Form
Advesme Form
Alpha-1 Proteinase Inhibitors Form (Aralast-NP, Glassia, Prolastin-C, Zemaira)
Amvuttra Form
Amyloid-Targeted Monoclonal Antibodies (MABs) Form (Kisunla, Leqembi)
Aphexda Form
Aqneursa Form
Attruby Form
Benlysta Form
Brand Medically Necessary Form
Breyanzi Form
Brineura Form
Brinsupri Form
Bylvay Form
Camzyos Form
Carvykti Form
Casgevy Form
CFTR Modulators Form (Alyftrek, Kalydeco, Orkambi, Symdeko, Trikafta)
Complement Inhibitors Form (Bkemv, Empaveli, Enjaymo, Epysqli, Fabhalta, Piasky, Soliris, Tavneos, Ultomiris, Voydeya, Zilbrysq)
Compounded Prescriptions Form
Corticotropin Form
Cough and Cold Medications Form
Crenessity
Crysvita Form
Cystaran Form
Daybue Form
DefenCath Form
Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides Form (Amondys-45, Exondys 51, Viltepso, Vyondys 53)
Duvyzat Form
Elevidys Form
Elitek Form
Epioxa Form
Evrysdi Form
Filspari Form
Filsuvez Form
Forzinity Form
Givlaari
Harliku Form
Hyftor Form
Imaavy Form
Imcivree Form
Immune Globulins Form
Ivabradine Form
Itvisma Form
Joenja Form
Jynarque Form
Kanuma Form
Kerendia Form
Korlym Form
Kuvan Form
Kygevvi Form
Kymriah Form
Loargys Form
Lodoco Form
Livmarli Form
Lyfgenia Form
Lynkuet Form
Miplyffa Form
Niktimvo Form
Mozobil Form
Myqorzo Form
Nuedexta Form
Omisirge Form
Onpattro Form
Palforzia Form
Palsonify Form
Palynziq Form
Provenge Form
Quantity Limits/Daily Dose Limits Form
Radicava Form
Rebyota Form
Rezdiffra Form
Rhapsido Form
Roctavian Form
Rystiggo Form
Skyclarys Form
Skysona Form
Spinraza Form
Tecartus Form
Tecelra Form
Tepezza Form
Therapeutic Duplication Form
Tzield Form
Uplizna Form
Vanrafia Form
Verkazia Form
Veozah Form
Vijoice Form
Vowst Form
Voxzogo Form
Voyxact Form
Vuity Form
Vyalev Form
Vyjuvek Form
Vyndamax Form
Vyndaqel Form
Vykat XR Form
Vyvgart Form
Wainua Form
Winrevair Form
Xofigo Form
Xolremdi Form
Xyrem and Xywav Form
Yartemlea Form
Yescarta Form
Yorvipath Form
Yuviwel Form
Zolgensma Form
Zycubo Form
Zynteglo Form
Pharmacy
Related links
Prior Authorization Clinical Guidelines
Prior Authorization General Requirements
Statewide Preferred Drug List (PDL)