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	Neulasta/Nivestym/Nyvepria/Releuko/Rolvedon/Stimufend/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
PHARM-262	Hepzato Kit PA
PHARM-263	Amtagvi PA
PHARM-266	Tevimbra PA
PHARM-268	Anktiva PA
PHARM-269	Ojemda PA
PHARM-270	Ryelo PA
PHARM-271	Lenmeldy PA
PHARM-272	Lymphir PA
PHARM-273	Niktimvo PA
PHARM-274	Voranigo PA
PHARM-276	Lazcluze PA
PHARM-277	Wegovy PA
PHARM-278	Ebglyss PA

Last Modified on Oct 23, 2024