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Due to heightened security alerts near the state capitol, OHCA will cancel the Jan. 20, 2021 board meeting and reschedule for next week. The safety of OHCA employees, board members and partners is of paramount importance. Once confirmed, the new date and time will be posted here.

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   Petition for Synagis Authorization
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 Kanjinti/Ogivri 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-148 Nexletol 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

 

Last Modified on Jan 21, 2021
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