Children's Medical Services Network Pharmacy Prior Authorization Forms

In order to obtain copies of prior authorization forms, please click on the name of the drug requiring prior authorization listed below. If you do not see the name of the drug needing prior authorization listed below you will need to select the Miscellaneous Pharmacy Prior Authorization Request form. If you need assistance, call (800) 603-1714.

These forms are (portable document format) files, which require the use of Acrobat Reader software. If you do not have Acrobat Reader, you may download the free software from the Adobe website.

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys [1.37MB]

Adult High Dose Antipsychotic [1.45MB] New 2/17/2017

Albumin [1.34MB]

Antidepressants (Age <6 years) [1.56MB] Updated 11/29/2017

Antipsychotic (Age <6 years of age) [1.44MB] Updated 11/29/2017

Antipsychotic (Age 6 to < 18 years of age) [1.51MB] Updated 11/29/2017

Buprenorphine Agents [1.9MB] Updated 5/24/2017

Cytogam [1.39MB] Updated 10/24/2017

Exondys [573KB] New 10/24/2017

Fuzeon [1.36MB]

Hepatitis C Agents [1.52MB] Updated 2/16/2018

HIV Diagnosis Verification [1.39MB] Updated 10/30/2017

Human Growth Hormone [1.42MB] Updated 3/9/2017

Human Growth Hormone for HIV Wasting in Adults (Serostim) [1.38MB]

Increlex [2.32MB] Updated 1/18/2017

Miscellaneous Pharmacy Prior Authorization Requests [1.32MB]

Nityr [591KB] New 3/27/2018

Request for Multi-Source Brand Drugs [491KB] Update 6/8/2016
This form is to be used if a patient's prescription was not covered because there is a generic, and the prescribing physician believes the patient has had a bad reaction to the generic; or the brand drug is otherwise medically necessary.

Neupogen/Leukine/Neulasta/Granix/Zarxio [613KB] Updated 5/23/2017

Opioids [1.88MB] New 1/26/2018

Oral Oncology Agents [1.43MB]

Orfadin [591KB] Updated 3/27/2018

Oxycontin [1.40MB] Updated 4/5/2018

Panretin [1.30MB] Updated 4/1/2015

Procrit/Aranesp [1.42MB] Updated 8/11/2017

Proleukin [1.35MB]

Selzentry [1.36MB]

Soma [1.69MB] Update 6/13/2016

Spinraza [1.80MB] New 10/24/2017

Stimulants and Strattera (<6 years of age) [490KB] New 8/18/2015

Supprelin LA [1.36MB]

Synagis - Weight Change [1.51MB]

Valcyte [583KB] Updated 3/20/2017

Vfend [1.37MB]