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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   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
PHARM-178 Zejula PA
PHARM-179 Vyepti PA


Last Modified on Feb 12, 2021
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