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PROVIDER FORMS

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Behavioral Health
Care Coordination
Claims & CPT Codes
Continuation of Care
Contracting
Medical Drugs - Commercial
Member Related
Pharmacy - Commercial

Drug Authorization

Abrysvo

ACA Copay Waiver - Aspirin 81 mg

ACA Copay Waiver - Breast Cancer Prevention Drugs

ACA Copay Waiver - High Dose Statins

Actemra SQ - Giant Cell Arteritis

Actemra SQ - Other Indications

Actemra SQ - Systemic Sclerosis-Associated Interstitial Lung Disease

Actimmune SQ

Adalimumab SQ
(Preferred: Cyltezo, Humira, Hyrimoz)

Adbry

Addyi

Adefovir Dipivoxil
(ADV, Generic Hepsera)

Afrezza

Agamree, Emflaza

Albuterol Inhalers
(Generic ProAir HFA, Generic Proventil HFA, Generic Ventolin HFA, Generic Xopenex, ProAir, Proventil HFA)

Alosetron, Lotronex, Viberzi

Ancobon, Flucytosine

Anticonvulsants, Antiepileptic Drugs, Antiseizure Drugs

Antidepressant Drugs
(Fetzima, Trintellix, vilazodone, Viibryd)

Antipsychotics (Children Ages 0 to 17)

Apokyn, Apomorphine Hydrochoride, Kynmobi

Arcalyst

Arformoterol Nebulizer Solution
(Generic Brovana & ABA)

Arikayce

Atypical Antipsychotics
(Asenapine, Saphris, Caplyta, Fanapt, Lurasidone, Latuda, Paliperidone, Invega, Rexulti, Vraylar)

Auryxia, Lanthanum Chewable Tablet, Fosrenol Chewable Tablet, Velphoro

Austedo

Auvelity ER

Auvi-Q Auto-Injector

Benign Prostate Hyperplasia (BPH)
(Tadalafil 2.5 or 5 mg)

Benlysta SQ

Bevespi Aerosphere, Breztri, Duaklir Pressair

Bimzelx

Brexafemme

Brixadi, Sublocade

Bronchitol

Butorphanol (Stadol) Nasal Spray

Bylvay

Cabenuva

Cablivi

Camzyos

Candesartan, Atacand, Candesartan-HCT, Atacand-HCT, Edarbi, Edarbyclor, Aliskiren, Tekturna, Tekturna-HCT

Carglumic Acid (Carbaglu)

Central Nervous System (CNS) Stimulants - Age 19 and Above

Central Nervous System (CNS) Stimulants - Binge Eating Disorder
(Vyvanse)

Central Nervous System (CNS) Stimulants - Non-Preferred Drugs for all Ages

Cholbam

Cibinqo

Cimzia SQ

Cinacalcet (Sensipar)

Continuous Glucose Monitors (CGM)

Contraceptive Medical Exception Request Form

Corlanor

Cosentyx SQ

Cresemba

Crinone

Cuvrior, Syprine, Trientine

Cystaran, Cystadrops

Daybue

Deferasirox, Exjade, Jadenu

Deferiprone Tablets, Ferriprox, Ferriprox Solution

Diacomit

Dichlorphenamide (Keveyis)

Dificid

Dihydroergotamine Mesylate (D.H.E. 45), Dihydroergotamine Mesylate (Migranal)

Dipetidyl Peptidase 4 (DPP4) Inhibitors

Dojolvi

Doptelet

Doxylamine-Pyridoxine (Diclegis)

Droxidopa (Northera)

Duavee

Duexis, Vimovo

Dupixent

Duvyzat

Egrifta

Emflaza

Emsam

Emverm

Enbrel

Enspryng

Entyvio

Eohilia

Epidiolex

Erythropoiesis Stimulating Agents (ESAs)
(Aranesp, Epogen, Mircera, Procrit, Retacrit)

Ethacrynic Acid (Edecrin)

Evrysdi

Exxua

Ezetimibe-Simvastatin (Vytorin)

Fabhalta

Fasenra SQ

Filspari

Filsuvez

Fintepla

Firdapse

Flector Patch

Forteo, Tymlos, Teriparatide

Furoscix

Galafold

Gastrointestinal Motility Drugs
(Amitiza, Ibsrela, Motegrity, Relistor, Trulance, Zelnorm)

Gattex

Gaucher Disease Drugs
(Cerdelga, Miglustat)

Glucagon Analogs
(GlucaGen HypoKit, Zegalogue)

Glucagon-Like Peptide (GLP-1) Receptor Agonists
(Bydureon Bcise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza)

Glycopyrrolate (Cuvposa)

Gonadotropin-Releasing Hormone (GnRH) Agonists

Graft-Versus-Host Disease (GVHD) Drugs
(Jakafi, Imbruvica)

Granulocyte Colony-Stimulating Factors (G-CSF)
(Granix, Neupogen, Nivestym, Releuko, Zarxio, Leukine, Fulphila, Fylnetra, Neulasta, Nyvepria, Rolvedon, Ryzneuta, Stimufend, Udenyca, Ziextenzo)

Grastek, Oralair

Hemangeol

Hepatitis-C Antiviral (HCV) Drugs
(Preferred: Sofosbuvir/Elpatasvir, Ledipasvir/Sofobuvir, Mavyret)
(Non-Preferred: Epclusa, Harvoni, Sovaldi, Viekira Pak, Vosevi, Zepatier)

Hereditary Angioedema Drugs - Acute Treatment
(Icatibant, Firazyr, Sajazir)

Hereditary Angioedema Drugs - Acute Treatment
(Ruconest)

Hereditary Angioedema Drugs - Prophylaxis
(Cinryze, Haegarda, Orladeyo, Takhzyro)

Human Chorionic Gonadotropin (hCG) - Pre-Pubertal Cryptorchidism
(Novarel, Pregnyl, Ovidrel, Chorionic Gonadotropin)

Icosapent Ethyl (Vascepa)

Ilumya SQ

Imcivree

Inbrija, Nourianz, Ongentys, Tolcapone, Tasmar

Increlex

Infertility Drugs (Group Specific Benefit)

Inflammatory Bowel Disease Drugs
(budesonide ER 9mg, Dipentum, Mesalamine DR 800mg)

Ingrezza

Inhaled Corticosteroid (ICS) with Long-Acting Beta-2 Agonist (LABA) Inhalers
(AirDuo Digihaler, AirDuo RespiClick, Budesonide-Formoterol, Dulera, Fluticasone-Salmeterol, Fluticasone Furoate-Vilanterol, Wixela Inhub)

Inhaled Corticosteroids (ICS) (Non-Preferred)
(Alvesco, ArmonAir Digihaler, Aasmanex, Flovent Diskus/HFA, fluticasone propionate Diskus/HFA)

Inpefa

Insomnia Drugs
(Belsomra, Dayvigo, doxepin, quazepam (Doral), Quviviq, ramelteon (Rozerem))

Insulins (Non-Preferred Long-Acting and Short-Acting)

Iqirvo, Ocaliva

Isturisa

Ivermectin, Stromectol Tablets

Javygtor, Sapropterin Dihydrochloride, Kuvan

Jesduvroq

Joenja

Juxtapid

Jynarque

Kalydeco

Kerendia

Kevzara

Kineret

Korlym

Koselugo

L-glutamine (Endari)

Lampit, Benznidazole

Libervant, Nayzilam, Valtoco

Litfulo

Livmarli

Livtencity

Lodoco

Long-Acting Muscarinic Antagonist (LAMA) Inhalers
(Lonhala Magnair, Tudorza Pressair, Yupelri)

Lupkynis

Marplan

Metyrosine, Demser, Phenoxybenazmine, Dibenzyline

Mifepristone (Mifeprex) 200mg Tablet

Mifepristone (Mifeprex) 300mg Tablet

Migraine Treatment - Injectable Calcitonin Gene-Related Peptide (CGRP) Antagonists
(Preferred: Aimovig, Emgality) (Non-Preferred: Ajovy)

Migraine Treatment - Oral Calcitonin Gene-Related Peptide (CGRP) Antagonists
(Preferred: Nurtec ODT, Qulipta) (Non-Preferred: Reyvow, Ubrelvy, Zavzpret)

Mulpleta

Multiple Sclerosis Drugs
(Bafiertam, Extavia, Gilenya 0.5mg, Kesimpta, Mavenclad, Mayzent, Ponvory, Vumerity, Zeposia)

Myalept

Myfembree, Oriahnn

Mytesi

Nasal Corticosteroids
(azelastine HCL-fluticasone propionate (Dymista), Beconase AQ, flunisolide nasal spray, mometasone (Nasonex), Omnaris, Qnasl, Xhance, Zetonna)

Natpara

Neupro

Nexletol, Nexlizet

Nitazoxanide (Alinia)

Nocdurna

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (Oral)

Nucala SQ - CRSWNP (Chronic Rhinosinusitis with Nasal Polyps)

Nucala SQ - Eosinophilic Granulomatosis Polyangiitis (EGPA)

Nucala SQ - Hypereosinophilic Syndome (HES)

Nucala SQ - Severe Eosinophilic Asthma (SEA)

Nuedexta

Nulibry

Nuplazid

Odactra House Dust Mite Allergen Extract

OFEV

Ohtuvayre

Olumiant

Omvoh

Oncology Drugs (Pharmacy Benefit)

Opfolda

Ophthalmic Drugs - Antihistamines
(Alocril, Alomide, Bepotastine Besilate 1.5%, Bepreve, Lastacaft, Zerviate)

Ophthalmic Drugs - Dry Eye
(Cequa, Lacrisert, Miebo, Restasis Multidose, Tyrvaya)

Ophthalmic Drugs - Glaucoma

Opioids

Opzelura

Orencia SQ

Orfadin, Nityr, Nitisinone

Orilissa

Orkambi

Osphena

Otezla

Otrexup, Rasuvo, Reditrex

Overactive Bladder Drugs
(Gemtesa, Myrbetriq, Fesoterodine, Toviaz)

Oxbryta

Oxervate

Oxlumo, Rivfloza

Palforzia

Palynziq Injection

Pancreatic Enzymes
(Pancreaze, Pertzye, Viokace)

Parathyroid Hormone Analogs
(Forteo, Tymlos, Teriparatide)

Penciclovir (Denavir)

Pimecrolimus (Elidel)

Pirfenidone (Esbriet)

Pitavastatin, Livalo, Zypitamag

Posaconazole DR Tablets, Noxafil DR Tablets, Noxafil IR/DR suspension

Potassium Binders
(Lokelma, Veltassa)

Pradaxa

Praluent, Repatha

Pretomanid

Prevymis Tablets

Procysbi

Promacta, Alvaiz

Proton Pump Inhibitors (PPI) Drugs (Non-Preferred)
(Dexlansoprazole, Omeprazole/Sodium Bicarbonate, Voquezna)

Pulmonary Arterial Hypertension (PAH) Drugs

Pulmonary Hypertension associated with Interstitial Lung Disease (PH-ILD)
(Tyvaso)

Pulmozyme

Pyrimethamine (Daraprim)

Pyrukynd

Qbrexza

Qelbree

Radicava ORS

Ragwitek

Ravicti

Rayaldee

Recombinant Growth Hormone (rhGH)
(Preferred: Omnitrope, Norditropin)
(Non-Preferred: Genotropin, Humatrope, Ngenla, Nutropin, Nutropin AQ, Saizen, Sogroya, Skytrofa, Zomacton)

Recorlev

Relyvrio

Repository Corticotropin Drugs - Infantile Spasms
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

Repository Corticotropin Drugs - Myositis
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

Repository Corticotropin Drugs - Nephrotic Syndrome
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

Repository Corticotropin Drugs - Ocular Diseases
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

Repository Corticotropin Drugs - Other Indications
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

Repository Corticotropin Drugs - Sarcoidosis
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

Repository Corticotropin Drugs - Systemic Lupus Erythematosus
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

Revcovi

Rezdiffra

Rezurock

Rinvoq, Rinvoq LQ

Rukobia

Saliva Substitutes
(Aquoral, Caphosol, NeutraSal, SalivaMax, Salivate Rx)

Savaysa

Savella

Serostim

Seysara

Siliq SQ

Simponi SQ

Sirturo

Skyclarys

Skyrizi SQ - Crohn's Disease & Ulcerative Colitis

Skyrizi SQ - Plaque Psoriasis & Psoriatic Arthritis

Sodium Oxbate Drugs
(Lumryz, Sodium Oxbate Oral Solution, Xyrem, Xywav)

Sodium Phenylbutyrate Drugs
(Sodium Phenylbutyrate, Buphenyl, Olpruva, Pheburane)

Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors (Non-Preferred)

Sohonos

Soliqua, Xultophy

Somatostatin Analog Drugs
(Bynfezia SQ, Sandostatin LAR Depot, Signafor SQ, Somavert SQ, Mycapssa Tablet)

Sotyktu

Spevigo

Spravato

Stelara SQ - Crohn's Disease & Ulcerative Colitis

Stelara SQ - Plaque Psoriasis & Psoriatic Arthritis

Stendra, Vardenafil (Group Specific Benefit)

Strensiq

Sucraid

Sunlenca

Sunosi

Symdeko

Synagis

Syndros Oral Solution

Taltz SQ

Tarpeyo

Tasimelteon, Hetlioz

Tavalisse

Tavneos

Testosterone Replacement Therapy
(Preferred: Testosterone Gel, Testosterone Injection, Testosterone Solution, Kyzatrex)
(Non-Preferred: Androderm, Natesto, Vogelxo)

Tetrabenazine, Xenazine

Tezspire SQ

Tiglutik

Tiopronin, Thiola

Tobi Podhaler

Tolvaptan (Samsca)

Topical Antibiotics Drugs
(Altabax, Xepi)

Topical Antifungal Drugs
(Ertaczo, luliconazole (Luzu), Mentax, naftifine (Naftin), oxiconazole (Oxistat), sulconazole (Exelderm))

Topical Corticosteroid Drugs

Topical Immunomodulator Drugs
(Zyclara, Imiquimod 3.75% , Picato, Klisyri)

Topical Phosphodiesterase 4 inhibitors
(Eucrisa 2%, Zoryve 0.15%)

Topical Psoriasis Drugs
(Vtama, Zoryve Cream)

Topical Retinoids and Acne Drugs - Skin Conditions

Topical Rosacea Drugs
(Brimonidine, Mirvaso, Rhofade, Ivermectin Cream, Soolantra, Zilxi)

Topical Seborrheic Dermatitis Drugs
(Zoryve Foam)

Tremfya

Trikafta

Uloric

Upneeq

Vecamyl

Velsipity

Vemlidy

Veozah

Verquvo

Vigabatrin Products
(Sabril, Vigadrone, vigabatrin, Vigafyde, Vigpoder)

Vijoice

Vivjoa

Vowst

Voxzogo

Voydeya

Vyleesi

Vyndaqel, Vyndamax

Wakix

Wegovy - Cardiovascular Event Risk Reduction

Weight Management Drugs (Group Specific Benefit)

Winrevair

Xadago

Xdemvy

Xeljanz, Xeljanz XR

Xenleta Tablets

Xifaxan

Xolair SQ

Xolremdi

Xphozah

Zeposia - Ulcerative Colitis

Zilbrysq

Zokinvy

Zolmitriptan (Zomig) Nasal Spray

Zontivity

Zorbtive

Ztalmy

Zurzuvae

Zyflo, Zileuton ER

Medication Exception

Maximum Daily Dosage Limit Exceptions Request Form

Pharmacy Medical Necessity Request Form

Prior Authorization

Compound Drugs

Member Transition of Service Form – Medical and Pharmacy
Pharmacy and Medical Drugs - Medicare

2025 Part D Prior Authorization Criteria

2025 Part D Step Therapy Criteria

Medicare Coverage Determination Request (English)

Medicare Coverage Determination Request (Spanish)

Part B Authorization Criteria

Medical Drug Authorization Request Form

Medicare Part B Drug Policy

Medicare Step Therapy Preferred Part B Medications
Prior Authorization and Hospital Admission Notification

Admission Notification

Hospital Admission Emergent Urgent Direct Admissions Form

Prior Authorization

Continuity of Care Authorization Form - Out of Network Providers

Medical Prior Authorization Request Form

Member Transition of Service Form – Medical and Pharmacy

Resources

Inpatient Discharge Planning Resources

No Authorization Required List Of Procedure Codes

Notice of Medicare Non-Coverage Form

Notice of Medicare Non-Coverage Form (Spanish)

Prior Authorization Requirements
Provider Data & Demographics
Quality Measures - HEDIS & Stars
Specialty Providers

Behavioral Health

PCP-Behavioral Health Coordination Form

Cardiology

NCH Cardiology FAQs

NCH Cardiology Matrix

Oncology

Medical Oncology & Hematology Prior Authorization Matrix

Ophthalmology

EMI Ophthalmology CPT Code List

Radiology

TBD