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OHCA Pharmacy Forms

 

PHARM-01 Drug Claim Form
PHARM-02 Compound Prescription Drug Claim
PHARM-03 Pharmacy Paid Claim Adjustment Request
PHARM-04 Universal Petition for Medication Authorization
PHARM-06 Petition for Tuberculosis Related Therapy Authorization
PHARM-07 Synagis PA
PHARM-09 Medication Therapy Management Services Referral Form
PHARM-11 Statement of Medical Necessity for Brand-Name Drug Override
PHARM-12 Statement of Medical Necessity for Early Fill Override
PHARM-14 Xolair PA
PHARM-16 Pharmacy Lock-In Referral
PHARM-17 ESA Petition
PHARM-18 Outpatient Medication Petition
PHARM-20 Growth Hormone PA
PHARM-23 Makena, Crinone, and Endometrin
PHARM-24 Botulinum Toxins
PHARM-25 State of Medical Necessity for Ingredient Duplication Override
PHARM-26 Sovaldi Initiation
PHARM-27 Olysio Initiation
PHARM-28 Hepatitis C Therapy Intent to Treat Contract
PHARM-29 Hepatitis C Therapy Pharmacy Agreement
PHARM-30 Hepatitis C Therapy Continuation
PHARM-33 Harvoni Initiation
PHARM-35 Diabetic Supplies PA
PHARM-37 Daklinza Initiation
PHARM-38 PCSK9 Inhibitor PA
PHARM-39 Kadcyla PA
PHARM-40 Halaven PA
PHARM-41 Afinitor PA
PHARM-42 Ixempra PA
PHARM-43 Tykerb PA
PHARM-44 Ibrance PA
PHARM-45 Perjeta PA
PHARM-46 Zepatier PA
PHARM-47 Nucala PA
PHARM-49 Hemophilia Dispensing
PHARM-50 Hemophilia PA  
PHARM-51 Hemophilia Consent
PHARM-52 Epclusa Initiation
PHARM-53 Hemophilia Standards of Care
PHARM-54 Jevtana PA
PHARM-55 Xtandi PA
PHARM-56 Zytiga/Yonsa PA
PHARM-57 Provenge PA
PHARM-58 Xofigo PA
PHARM-59 Coltellic PA
PHARM-60 Erivedge PA
PHARM-61 Imlygic PA
PHARM-62 Keytruda PA
PHARM-63 Odomzo PA
PHARM-64 Opdivo PA
PHARM-65 Tafinlar PA
PHARM-66 Yervoy PA
PHARM-67 Zelboraf PA
PHARM-68 Mekinist PA
PHARM-69 Cinqair PA
PHARM-70 Kisqali PA
PHARM-71 Spinraza PA
PHARM-72 Vosevi PA
PHARM-73 Nerlynx PA
PHARM-74 Mavyret Initiation
PHARM-75 Alecensa PA
PHARM-76 Alunbrig PA
PHARM-77 Cyramza PA
PHARM-78 Gilotrif PA
PHARM-79 Tagrisso PA
PHARM-80 Tarceva PA
PHARM-81 Tecentriq PA
PHARM-82 Xalkori PA
PHARM-83 Zykadia PA
PHARM-84 Verzenio PA
PHARM-85 Kymriah PA
PHARM-86                         Fasenra PA
PHARM-87          Bavencio PA
PHARM-88 Besponsa PA
PHARM-89 Blincyto PA
PHARM-90 Bosulif PA
PHARM-92 Iclusig PA
PHARM-93 Sprycel PA
PHARM-94 Synribo PA
PHARM-95 Tasigna PA
PHARM-96 Lynparza PA
PHARM-97 Yescarta PA
PHARM-98           Hemlibra PA
PHARM-99 Arzerra PA
PHARM-100 Gazyva PA
PHARM-101 Imbruvica PA
PHARM-102 Venclexta PA
PHARM-103 Zydelig PA
PHARM-104 Aimovig PA
PHARM-105 Braftovi PA
PHARM-106 Mektovi PA
PHARM-107 Ajovy PA
PHARM-108          Emgality PA
PHARM-109 Libtayo PA
PHARM-110 Vizimpro PA
PHARM-111 Opioid MME Limit Override
PHARM-112 Talzenna PA
PHARM-113 Lutathera PA
PHARM-114 Lorbrena PA
PHARM-115 Dupixent PA
PHARM-116 Copiktra PA
PHARM-117 Vitrakvi PA
PHARM-118           Intravenous Iron Therapy PA
PHARM-119          Imfinzi PA
PHARM-120 Balversa PA
PHARM-121           Piqray PA
PHARM-122 Zolgensma PA
PHARM-123 Adcetris PA
PHARM-124 Beleodaq PA
PHARM-125 Calquence PA
PHARM-126 Folotyn PA
PHARM-127 Istodax PA
PHARM-128 Poteligeo PA
PHARM-129 Truxima PA
PHARM-130 Zevalin PA
PHARM-131 Zolinza PA
PHARM-132 Turalio PA  
PHARM-133 Herzuma/Kanjinti/Ogivri/Ontruzant/Trazimera PA
PHARM-134 Rozlytrek PA
PHARM-135 Inrebic PA
PHARM-136 Step Therapy Exception  
PHARM-137 Elzonris PA
PHARM-138           DUR Public Comment Registration  
PHARM-139 Continuous Glucose Monitor (CGM) PA
PHARM-140 Brukinsa PA
PHARM-141 Nubeqa PA
PHARM-142 Erleada PA
PHARM-143 Polivy PA
PHARM-144 Enhertu PA
PHARM-145 Padcev PA
PHARM-146 Azedra PA
PHARM-147 Sarclisa PA
PHARM-148 Nexletol/Nexlizet PA
PHARM-149 Koselugo PA
PHARM-150 Tukysa PA
PHARM-151 Pemazyre PA
PHARM-152 Trodelvy PA
PHARM-153 Asparlas PA
PHARM-154 Daurismo PA
PHARM-155 Idhifa PA
PHARM-156 Lumoxiti PA
PHARM-157 Tibsovo PA
PHARM-158 Xospata PA
PHARM-159 Qinlock PA
PHARM-160 Retevmo PA
PHARM-161 Tabrecta PA
PHARM-162 Aliqopa PA
PHARM-163 Ayvakit PA
PHARM-164 Bynfezia PA
PHARM-165 Pemfexy PA
PHARM-166 Zirabev PA
PHARM-167 Tazverik PA
PHARM-168 Zepzelca PA
PHARM-169 Phesgo PA
PHARM-170 Evrysdi PA
PHARM-171 Blenrep PA
PHARM-172 Inqovi PA
PHARM-173 Gavreto PA
PHARM-174 Onureg PA
PHARM-175 Spravato PA
PHARM-176           Tecartus PA
PHARM-177 Rubraca PA
PHARM-178 Zejula PA
PHARM-179 Vyepti PA
PHARM-180 Lenvima PA
PHARM-181 Darzalex/Darzalex Faspro PA
PHARM-182 Empliciti PA
PHARM-183 Ninlaro PA
PHARM-184 Xpovio PA

 

PHARM-01 Drug Claim Form
PHARM-02 Compound Prescription Drug Claim
PHARM-03 Pharmacy Paid Claim Adjustment Request
PHARM-04 Universal Petition for Medication Authorization
PHARM-05 Pharmacy Prior Authorization Amendment Form
PHARM-06 Petition for Tuberculosis Related Therapy Authorization
PHARM-07A Synagis Initiation Form
PHARM-07B Synagis Continuation Form
PHARM-09 Medication Therapy Management Services Referral Form
PHARM-11 Statement of Medical Necessity for Brand-Name Drug Override
PHARM-12 Statement of Medical Necessity for Early Fill Override
PHARM-14 Xolair PA
PHARM-16 Pharmacy Lock-In Referral
PHARM-17 ESA Petition
PHARM-18 Outpatient Medication Petition
PHARM-20 Growth Hormone PA
PHARM-23 Crinone and Endometrin
PHARM-24 Botulinum Toxins
PHARM-25 State of Medical Necessity for Ingredient Duplication Override
PHARM-26 Sovaldi Initiation
PHARM-28 Hepatitis C Therapy Intent to Treat Contract
PHARM-29 Hepatitis C Therapy Pharmacy Agreement
PHARM-30 Hepatitis C Therapy Continuation
PHARM-33 Harvoni Initiation
PHARM-35 Diabetic Supplies PA
PHARM-38 PCSK9 Inhibitor PA
PHARM-39 Kadcyla PA
PHARM-40 Halaven PA
PHARM-41 Afinitor PA
PHARM-42 Ixempra PA
PHARM-43 Tykerb PA
PHARM-44 Ibrance PA
PHARM-45 Perjeta PA
PHARM-46 Zepatier PA
PHARM-47 Nucala PA
PHARM-49 Hemophilia Dispensing
PHARM-50 Hemophilia PA  
PHARM-51 Hemophilia Consent
PHARM-52 Sofosbuvir/Velpatasvir Initiation
PHARM-53 Hemophilia Standards of Care
PHARM-54 Jevtana PA
PHARM-55 Xtandi PA
PHARM-56 Zytiga/Yonsa PA
PHARM-57 Provenge PA
PHARM-58 Xofigo PA
PHARM-59 Cotellic PA
PHARM-60 Erivedge PA
PHARM-61 Imlygic PA
PHARM-62 Keytruda PA
PHARM-63 Odomzo PA
PHARM-64 Opdivo PA
PHARM-65 Tafinlar PA
PHARM-66 Yervoy PA
PHARM-67 Zelboraf PA
PHARM-68 Mekinist PA
PHARM-69 Cinqair PA
PHARM-70 Kisqali PA
PHARM-71 Spinraza PA
PHARM-72 Vosevi PA
PHARM-73 Nerlynx PA
PHARM-75 Alecensa PA
PHARM-76 Alunbrig PA
PHARM-77 Cyramza PA
PHARM-78 Gilotrif PA
PHARM-79 Tagrisso PA
PHARM-80 Tarceva PA
PHARM-81 Tecentriq PA
PHARM-82 Xalkori PA
PHARM-83 Zykadia PA
PHARM-84 Verzenio PA
PHARM-85 Kymriah PA
PHARM-86                         Fasenra PA
PHARM-87          Bavencio PA
PHARM-88 Besponsa PA
PHARM-89 Blincyto PA
PHARM-90 Bosulif PA
PHARM-92 Iclusig PA
PHARM-93 Sprycel PA
PHARM-94 Synribo PA
PHARM-95 Tasigna PA
PHARM-96 Lynparza PA
PHARM-97 Yescarta PA
PHARM-98           Hemlibra PA
PHARM-99 Arzerra PA
PHARM-100 Gazyva PA
PHARM-101 Imbruvica PA
PHARM-102 Venclexta PA
PHARM-103 Zydelig PA
PHARM-104 Aimovig PA
PHARM-105 Braftovi PA
PHARM-106 Mektovi PA
PHARM-107 Ajovy PA
PHARM-108          Emgality PA
PHARM-109 Libtayo PA
PHARM-110 Vizimpro PA
PHARM-111 Opioid MME Limit Override
PHARM-112 Talzenna PA
PHARM-113 Lutathera PA
PHARM-114 Lorbrena PA
PHARM-115 Dupixent PA
PHARM-116 Copiktra PA
PHARM-117 Vitrakvi PA
PHARM-118           Intravenous Iron Therapy PA
PHARM-119          Imfinzi PA
PHARM-120 Balversa PA
PHARM-121           Piqray PA
PHARM-122 Zolgensma PA
PHARM-123 Adcetris PA
PHARM-124 Beleodaq PA
PHARM-125 Calquence PA
PHARM-126 Folotyn PA
PHARM-127 Istodax PA
PHARM-128 Poteligeo PA
PHARM-129 Truxima/Ruxience PA
PHARM-130 Zevalin PA
PHARM-131 Zolinza PA
PHARM-132 Turalio PA  
PHARM-133 Herceptin/Herceptin Hylecta/Herzuma/Kanjinti/Ogivri/Ontruzant/Trazimera PA
PHARM-134 Rozlytrek PA
PHARM-135 Inrebic PA
PHARM-136 Step Therapy Exception  
PHARM-137 Elzonris PA
PHARM-138           DUR Public Comment Registration  
PHARM-139 Continuous Glucose Monitor (CGM) PA
PHARM-140 Brukinsa PA
PHARM-141 Nubeqa PA
PHARM-142 Erleada PA
PHARM-143 Polivy PA
PHARM-144 Enhertu PA
PHARM-145 Padcev PA
PHARM-146 Azedra PA
PHARM-147 Sarclisa PA
PHARM-148 Nexletol/Nexlizet PA
PHARM-149 Koselugo PA
PHARM-150 Tukysa PA
PHARM-151 Pemazyre PA
PHARM-152 Trodelvy PA
PHARM-153 Asparlas/Oncaspar PA
PHARM-154 Daurismo PA
PHARM-155 Idhifa PA
PHARM-156 Lumoxiti PA
PHARM-157 Tibsovo PA
PHARM-158 Xospata PA
PHARM-159 Qinlock PA
PHARM-160 Retevmo PA
PHARM-161 Tabrecta PA
PHARM-162 Aliqopa PA
PHARM-163 Ayvakit PA
PHARM-164 Bynfezia PA
PHARM-165 Pemfexy PA
PHARM-166 Mvasi PA
PHARM-167 Tazverik PA
PHARM-168 Zepzelca PA
PHARM-169 Phesgo PA
PHARM-170 Evrysdi PA
PHARM-171 Blenrep PA
PHARM-172 Inqovi PA
PHARM-173 Gavreto PA
PHARM-174 Onureg PA
PHARM-175 Spravato PA
PHARM-176           Tecartus PA
PHARM-177 Rubraca PA
PHARM-178 Zejula PA
PHARM-179 Vyepti PA
PHARM-180 Lenvima PA
PHARM-181 Darzalex/Darzalex Faspro PA
PHARM-182 Empliciti PA
PHARM-183 Ninlaro PA
PHARM-184 Xpovio PA
PHARM-185 Margenza PA
PHARM-186 Orgovyx PA
PHARM-188 Monjuvi PA
PHARM-189 Breyanzi PA
PHARM-190 Jelmyto PA
PHARM-191 Tepmetko PA
PHARM-193 Nurtec PA
PHARM-194 Fotivda PA
PHARM-195 Danyelza PA
PHARM-196 Truseltiq PA
PHARM-197 Cabometyx PA
PHARM-198 Jakafi PA
PHARM-199 Rezurock PA
PHARM-200 Abecma PA
PHARM-203 Jemperli PA
PHARM-204 Leqvio PA
PHARM-205 Qulipta PA
PHARM-206 Scemblix PA
PHARM-207 Erwinaze/Rylaze PA
PHARM-208 Fulphila/Nivestym/Neulasta/Releuko/Udenyca PA
PHARM-209 Zynlonta PA
PHARM-210 Exkivity PA
PHARM-211 Lumakras PA
PHARM-212 Rybrevant PA
PHARM-213 Cosela PA
PHARM-214 Camcevi PA
PHARM-215 Pluvicto PA
PHARM-216 Tivdak PA
PHARM-217 Lonsurf PA
PHARM-218 Stivarga PA
PHARM-219 Welireg PA
PHARM-220 Besremi PA
PHARM-221 Vonjo PA
PHARM-222 Adbry PA
PHARM-223 Carvykti PA
PHARM-224 Tecvayli PA
PHARM-225 Tezspire PA
PHARM-226 Kimmtrak PA
PHARM-227 Opdualag PA
PHARM-228 Lytgobi PA
PHARM-229 Pedmark PA
PHARM-230 Vijoice PA
PHARM-231 Hyftor PA
PHARM-232 Elahere PA
PHARM-233 Imjudo PA
PHARM-234 Lunsumio PA
PHARM-235 Zynteglo PA
PHARM-236 Skysona PA
PHARM-238 Jaypirca PA
PHARM-239 Krazati PA
PHARM-240 Rezlidhia PA
PHARM-241 Orserdu PA
PHARM-242 Adstiladrin PA
PHARM-243 Zynyz PA
PHARM-244 Epkinly PA
PHARM-245 Omisirge PA
PHARM-246 Tzield PA
PHARM-247 Vyjuvek PA
PHARM-248 Elevidys PA
PHARM-249 Akeega PA
PHARM-250 Columvi PA
PHARM-251 Elrexfio PA
PHARM-252 Talvey PA
PHARM-253 Vanflyta PA
PHARM-254 Augtyro PA
PHARM-255 Fruzaqla PA
PHARM-256 Truqap PA
PHARM-257 Loqtorzi PA
PHARM-258 Zurzuvae PA
PHARM-259 Iwilfin PA
PHARM-260 Ogsiveo PA
PHARM-261 Kepivance PA
Last Modified on Apr 02, 2024
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Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

Contact Us

The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. This data is treated as confidential and is stored securely in accordance with applicable law and regulations. OHCA may share this personally identifiable data with its authorized business associates, government agencies with jurisdiction over the OHCA, or as otherwise required or permitted by applicable law.