Skip to main content

To learn about SoonerCare's citizenship requirements, view our eligibility guidelines. Para obtener más información sobre los requisitos de ciudadanía de SoonerCare, consulte nuestras pautas de elegibilidad. 

OHCA Pharmacy Forms

 

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

 

PHARM-01Drug Claim Form
PHARM-02Compound Prescription Drug Claim
PHARM-03Pharmacy Paid Claim Adjustment Request
PHARM-04Universal Petition for Medication Authorization
PHARM-05Pharmacy Prior Authorization Amendment Form
PHARM-06Petition for Tuberculosis Related Therapy Authorization
PHARM-09Medication Therapy Management Services Referral Form
PHARM-11Statement of Medical Necessity for Brand-Name Drug Override
PHARM-12Statement of Medical Necessity for Early Fill Override
PHARM-14Omlyclo & Xolair PA
PHARM-16Pharmacy Lock-In Referral
PHARM-17ESA Petition
PHARM-18Outpatient Medication Petition
PHARM-20Growth Hormone PA
PHARM-21Voxzogo & Yuviwel PA
PHARM-23Crinone and Endometrin
PHARM-24Botulinum Toxins
PHARM-25State of Medical Necessity for Ingredient Duplication Override
PHARM-26Sovaldi Initiation
PHARM-28Hepatitis C Therapy Intent to Treat Contract
PHARM-29Hepatitis C Therapy Pharmacy Agreement
PHARM-30Hepatitis C Therapy Continuation
PHARM-33Harvoni Initiation
PHARM-35Diabetic Supplies PA
PHARM-38Repatha PA
PHARM-39Kadcyla PA
PHARM-40Halaven PA
PHARM-41Afinitor PA
PHARM-42Ixempra PA
PHARM-43Tykerb PA
PHARM-44Ibrance PA
PHARM-45Perjeta PA
PHARM-46Zepatier PA
PHARM-47Nucala PA
PHARM-49Hemophilia Dispensing
PHARM-50Hemophilia PA  
PHARM-51Hemophilia Consent
PHARM-52Sofosbuvir/Velpatasvir Initiation
PHARM-53Hemophilia Standards of Care
PHARM-54Jevtana PA
PHARM-55Xtandi PA
PHARM-56Zytiga/Yonsa PA
PHARM-57Provenge PA
PHARM-58Xofigo PA
PHARM-59Cotellic PA
PHARM-60Erivedge PA
PHARM-61Imlygic PA
PHARM-62Keytruda PA
PHARM-63Odomzo PA
PHARM-64Opdivo PA
PHARM-65Tafinlar PA
PHARM-66Yervoy PA
PHARM-67Zelboraf PA
PHARM-68Mekinist PA
PHARM-69Cinqair PA
PHARM-70Kisqali PA
PHARM-71Spinraza PA
PHARM-72Vosevi PA
PHARM-73Nerlynx PA
PHARM-75Alecensa PA
PHARM-76Alunbrig PA
PHARM-77Cyramza PA
PHARM-78Gilotrif PA
PHARM-79Tagrisso PA
PHARM-80Tarceva PA
PHARM-81Tecentriq PA
PHARM-82Xalkori PA
PHARM-83Zykadia PA
PHARM-84Verzenio PA
PHARM-85Kymriah PA
PHARM-86Fasenra PA
PHARM-87         Bavencio PA
PHARM-88Besponsa PA
PHARM-89Blincyto PA
PHARM-90Bosulif PA
PHARM-92Iclusig PA
PHARM-93Sprycel PA
PHARM-95Tasigna PA
PHARM-96Lynparza PA
PHARM-97Yescarta PA
PHARM-98Non-Factor Hemophilia PA
PHARM-100Gazyva PA
PHARM-101Imbruvica PA
PHARM-102Venclexta PA
PHARM-103Zydelig PA
PHARM-104Aimovig PA
PHARM-105Braftovi PA
PHARM-106Mektovi PA
PHARM-107Ajovy PA
PHARM-108Emgality PA
PHARM-109Libtayo PA
PHARM-110Vizimpro PA
PHARM-111Opioid MME Limit Override
PHARM-112Talzenna PA
PHARM-113Lutathera PA
PHARM-114Lorbrena PA
PHARM-115Dupixent PA
PHARM-116Copiktra PA
PHARM-117Vitrakvi PA
PHARM-118Intravenous Iron Therapy PA
PHARM-119Imfinzi PA
PHARM-120Balversa PA
PHARM-121Piqray PA
PHARM-122Zolgensma PA
PHARM-123Adcetris PA
PHARM-124Beleodaq PA
PHARM-125Calquence PA
PHARM-126Folotyn PA
PHARM-127Istodax PA
PHARM-128Poteligeo PA
PHARM-130Zevalin PA
PHARM-131Zolinza PA
PHARM-132Turalio PA  
PHARM-133Herceptin/Herceptin Hylecta/Herzuma/Kanjinti/Ogivri/Ontruzant/Trazimera PA
PHARM-134Rozlytrek PA
PHARM-135Inrebic PA
PHARM-136Step Therapy Exception  
PHARM-137Elzonris PA
PHARM-138          DUR Public Comment Registration  
PHARM-139Continuous Glucose Monitor (CGM) PA
PHARM-140Brukinsa PA
PHARM-141Nubeqa PA
PHARM-142Erleada PA
PHARM-143Polivy PA
PHARM-144Enhertu PA
PHARM-145Padcev PA
PHARM-147Sarclisa PA
PHARM-148Nexletol/Nexlizet PA
PHARM-149Koselugo PA
PHARM-150Tukysa PA
PHARM-151Pemazyre PA
PHARM-152Trodelvy PA
PHARM-153Asparlas/Oncaspar PA
PHARM-154Daurismo PA
PHARM-155Idhifa PA
PHARM-157Tibsovo PA
PHARM-158Xospata PA
PHARM-159Qinlock PA
PHARM-160Retevmo PA
PHARM-161Tabrecta PA
PHARM-163Ayvakit PA
PHARM-164Bynfezia PA
PHARM-165Pemfexy PA
PHARM-166Bevacizumab PA
PHARM-168Zepzelca PA
PHARM-169Phesgo PA
PHARM-170Evrysdi PA
PHARM-171Blenrep PA
PHARM-172Inqovi PA
PHARM-173Gavreto PA
PHARM-174Onureg PA
PHARM-175Spravato PA
PHARM-176Tecartus PA
PHARM-177Rubraca PA
PHARM-178Zejula PA
PHARM-179Vyepti PA
PHARM-180Lenvima PA
PHARM-181Darzalex/Darzalex Faspro PA
PHARM-182Empliciti PA
PHARM-183Ninlaro PA
PHARM-184Xpovio PA
PHARM-185Margenza PA
PHARM-186Orgovyx PA
PHARM-188Monjuvi PA
PHARM-189Breyanzi PA
PHARM-190Jelmyto PA
PHARM-191Tepmetko PA
PHARM-193Nurtec PA
PHARM-194Fotivda PA
PHARM-195Danyelza PA
PHARM-197Cabometyx PA
PHARM-198Jakafi PA
PHARM-199Rezurock PA
PHARM-200Abecma PA
PHARM-203Jemperli PA
PHARM-204Leqvio PA
PHARM-205Qulipta PA
PHARM-206Scemblix PA
PHARM-207Erwinaze/Rylaze PA
PHARM-208G-CSF PA
PHARM-209Zynlonta PA
PHARM-210Exkivity PA
PHARM-211Lumakras PA
PHARM-212Rybrevant PA
PHARM-213Cosela PA
PHARM-215Pluvicto PA
PHARM-216Tivdak PA
PHARM-217Lonsurf PA
PHARM-218Stivarga PA
PHARM-219Welireg PA
PHARM-220Besremi PA
PHARM-221Vonjo PA
PHARM-222Adbry PA
PHARM-223Carvykti PA
PHARM-224Tecvayli PA
PHARM-225Tezspire PA
PHARM-226Kimmtrak PA
PHARM-227Opdualag PA
PHARM-228Lytgobi PA
PHARM-229Pedmark PA
PHARM-230Vijoice PA
PHARM-231Hyftor PA
PHARM-232Elahere PA
PHARM-233Imjudo PA
PHARM-234Lunsumio PA
PHARM-235Zynteglo PA
PHARM-236Skysona PA
PHARM-238Jaypirca PA
PHARM-239Krazati PA
PHARM-240Rezlidhia PA
PHARM-241Orserdu PA
PHARM-242Adstiladrin PA
PHARM-243Zynyz PA
PHARM-244Epkinly PA
PHARM-245Omisirge PA
PHARM-246Tzield PA
PHARM-247Vyjuvek PA
PHARM-248Elevidys PA
PHARM-249Akeega PA
PHARM-250Columvi PA
PHARM-251Elrexfio PA
PHARM-252Talvey PA
PHARM-253Vanflyta PA
PHARM-254Augtyro PA
PHARM-255Fruzaqla PA
PHARM-256Truqap PA
PHARM-257Loqtorzi PA
PHARM-258Zurzuvae PA
PHARM-259Iwilfin PA
PHARM-260Ogsiveo PA
PHARM-261Kepivance PA
PHARM-262Hepzato Kit PA
PHARM-264Lyfgenia PA
PHARM-265Casgevy PA
PHARM-266Tevimbra PA
PHARM-268Anktiva PA
PHARM-269Ojemda PA
PHARM-270Rytelo PA
PHARM-271Lenmeldy PA
PHARM-272Lymphir PA
PHARM-273Niktimvo PA
PHARM-274Voranigo PA
PHARM-275Tecelra PA
PHARM-276Lazcluze PA
PHARM-277Wegovy PA
PHARM-278Ebglyss PA
PHARM-279Nemluvio PA
PHARM-280Itovebi PA
PHARM-281Vyloy PA
PHARM-282Danziten PA
PHARM-283Boruzu PA
PHARM-284Bizengri PA
PHARM-285Kebilidi PA
PHARM-286Revuforj PA
PHARM-287Ziihera PA
PHARM-288Aucatzyl PA
PHARM-289Datroway PA
PHARM-291Grafapex PA
PHARM-292Gomekli PA
PHARM-293Romvimza PA
PHARM-295Fyarro PA
PHARM-296Ryoncil PA
PHARM-299Avmapki Fakzynja Co-Pack PA
PHARM-300Emrelis PA
PHARM-301Imdelltra PA
PHARM-302Zusduri PA
PHARM-303Ibtrozi PA
PHARM-304Lynozyfic PA
PHARM-305Hernexeos PA
PHARM-306Modeyso PA
PHARM-307Praluent PA
PHARM-308Encelto PA
PHARM-309Inlexzo PA
PHARM-310Zevaskyn PA
PHARM-311Inluriyo PA
PHARM-312Beizray PA
PHARM-313Papzimeos PA
PHARM-314Hyrnuo PA
PHARM-315Itvisma PA
PHARM-316Zepbound PA
PHARM-317Ensacove PA
PHARM-318Komzifti PA
PHARM-319Exdensur PA
PHARM-320Unloxcyt PA
PHARM-321Hereditary Angioedema (HAE) Medications PA
PHARM-322IGIV-IGSC Meds PA
PHARM-323Lifyorli PA
PHARM-324Vistogard PA
PHARM-325Favlyxa PA
PHARM-326Decnupaz PA
PHARM-327Avgemsi PA
PHARM-328Veppanu PA
PHARM-329Hepcludex PA
Last Modified on Aug 26, 2026