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PROVIDER FORMS

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

Drug Authorization

Abrysvo

Actemra (Diagnosis of Giant Cell Arteritis)

Actemra (Diagnosis of Systemic Sclerosis-Associated Interstitial Lung Disease)

Actemra SQ (Pharmacy) (Non-Preferred)

ActimmuneSQ

Adalimumab (Preferred) Products (Cyltezo | Humira | Hyrimoz)

Adbry

Addyi

Adefovir Dipivoxil (ADV, Generic Hepsera)

Afrezza

Albuterol Inhalers (Albuterol HFA (Generic ProAir HFA) | Albuterol HFA (Generic Proventil HFA) | Albuterol HFA (Generic Ventolin HFA) | Lavalbuterol HFA (Generic Xopenex) | ProAir Digihaler/HFA/Respiclick | Proventil HFA)

Alopliptin | Alogliptin-Pioglitazone | Alogliptin-Metformin | Kazano | Saxagliptin-Metformin ER (KombiglyzeXR) | Nesina | Saxagliptin (Onglyza) | Oseni

Alosetron (Lotronex) | Viberzi

Ancobon | Flucytosine

Anticonvulsants | Antiepileptic Drugs | Antiseizure Drugs

Antipsychotics-Children (0-17) - COMMERCIAL ONLY

Apokyn | Apomorphine Hydrochoride | Kynmobi

Aranesp | Epogen | Procrit | Retacrit

Arcalyst

Arformoterol Nebulizer Solution (Generic Brovana & ABA)

Arikayce

Aspirin 81 mg (ACA Copay Wavier)

Atypical Antipsychotics (Asenapine (Saphris) | Caplyta | Fanapt | lurasidone (Latuda) | Paliperidone (Invega) | Rexulti | Vraylar)

Auryxia | lanthanum chewable tablet (Fosrenol) | Velphoro

Austedo

Auvelity ER

Auvi-Q Auto-Injector

Benign Prostate Hyperplasia (BPH) (tadalafil 2.5 or 5 mg (BPH) ONLY)

Benlysta (Pharmacy)

Bevespi Aerosphere | Breztri | Duaklir Pressair

Bimzelx

Breast Cancer Prevention Drugs (ACA Copay Wavier)

Brexafemme

Brixadi│Sublocade

Bronchitol

Butorphanol (Stadol) Nasal Spray

Bylvay

Cabenuva (Pharmacy)

Cablivi

Camzyos

Candesartan (Atacand) | Candesartan-HCTZ (Atacand HCT) | Edarbi | Edarbyclor | Aliskiren (Tekturna) | Tekturna HCT

Carglumic Acid (Carbaglu)

Central Nervous System (CNS) Stimulants (Age 19 and Above) (Adhansia XR | Adzenys XR-ODT/ER | Amphetamine/Dextroamphetamine (Adderall) | Amphetamine/Dextroamphetamine ER (Adderall XR) | Amphetamine Sulfate (Evekeo) | Azstarys | Cotempla XR/ODT | Dexmethylphenidate (Focalin) | Dexmethylphenidate ER (Focalin XR) | Dextroamphetamine (Zenzedi) | Dextroamphetamine (ProCentra) | Dextroamphetamine (Dextrostat) | Dextroamphetamine ER (Dexedrine Spansule) | Dyanavel XR | Evekeo ODT | Jornay PM | Methamphetamine (Desoxyn) | Methylphenidate ER (Aptensio XR) | Methylphenidate ER (Concerta) | Methylphenidate TID Patch (Daytrana) | Methylphenidate ER (Ritalin SR/Metadate ER) | Methylphenidate (Ritalin/Methylin) | Methylphenidate LA (Ritalin LA) | Methylphenidate CD (Metadate CD) | Mydays | Quillichew ER | Quillivant XR | Vyvanse)

Central Nervous System (CNS) Stimulants (Non-Preferred) (Adhansia XR | Adzenys XR-ODT | Adzenys ER Susp | Amphetamine Sulfate (Evekeo) | Azstarys | Cotempla XR-ODT | Dyanavel XR | Evekeo ODT | Jornay PM | Methylphenidate ER (Aptensio XR) | Methylphenidate TD Patch (Daytrana) | Mydayis | Quillichew ER | Quillivant XR

Cequa | Lacrisert | Tyrvaya

Cholbam

Cialis | tadalafil (BPH) ONLY

Cibinqo

Cimzia SQ (Pharmacy benefit Prefilled Syringe)

Cinacalcet (Generic Sensipar)

Cinacalcet (Sensipar)

Continuous Glucose Monitors (CGM) & Subcutaneous Insulin Pumps (PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)

Corlanor

Cosentyx SQ (Pharmacy Benefit)

Cresemba (Pharmacy)

Crinone

Cuvrior | Syprine | Trientine

Cystaran | Cystadrops

Daybue

Deferasirox (Exjade) | Deferasirox (Jadenu)

Deferiprone Tablets (Ferriprox) | Ferriprox Solution

Diacomit

Dichlorphenamide (Keveyis)

Dificid

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

Dipetidyl Peptidase 4 (DPP4) Inhibitors (alogliptin (Nesina ABA) | alogliptin-pioglitazone (Oseni ABA)| alogliptin-metformin (Kazano ABA)| Kazano | Nesina | Oseni | saxagliptin (Onglyza) | saxagliptin-metformin ER (Kombigliyze XR) | Zituvio)

Dojolvi

Doptelet

Doxylamine-Pyridoxine (Diclegis)

Droxidopa (Northera)

Dry Eye Medications (Cequa | Lacrisert | Miebo | Restasis Multidose |Tyrvaya)

Duavee

Duexis | Vimovo

Dupixent

Egrifta

Emflaza

Emsam

Emverm

Enbrel

Endari

Enspryng

Entyvio

Epidiolex

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

Ethacrynic Acid (Edecrin)

Eucrisa

Evrysdi

Ezetimibe-Simvastatin (Vytorin)

Fasenra SQ (Pharmacy)

Fetzima | Trintellix | Vilazodone (Viibryd)

Filspari

Fintepla

Firdapse

Flector Patch

Forteo | Tymlos | teriparatide

Furoscix

Galafold

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

Gattex

Gaucher Disease Drugs (Substrate Reduction Therapy) (Cerdelga | Miglustat) (Pharmacy)

Glaucoma Drugs (Betimol | Betoptic-S | brimonidine 0.1% (Alphagan-P)| Rhopressa | Rocklatan | Simbrinza | tafluprost (Zioptan) | travoprost 0.004% (Travatan Z) | Vyzulta)

Glaucoma Drugs (Betimol | Betoptic-S | Rhopressa | Rocklatan | Simbrinza | travoprost 0.004% (Travatan Z) | Vyzulta | tafluprost (Zioptan)

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 Agonists (GnRH) (Pharmacy)

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

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

Grastek | Oralair

Hemangeol

Hepatitis-C Antiviral (HCV) Drugs (PREFERRED: Sofosbuvir/Elpatasvir | Ledipasvir/Sofobuvir | Mavyret) (NON-PREFERRED: Epclusa | Harvoni | Sovaldi | Viekira Pak | Vosevi | Zepatier)

High Dose Statins (ACA Copay Wavier)

Icatibant (Firazyr) | Sajazir (Firazyr) (Pharmacy)

Icosapent Ethyl (Vascepa)

Ilumya (Pharmacy)

Imcivree

Inbrija | Nourianz | Ongentys | Tolcapone (Tasmar)

Increlex

Infertility Drugs (cetrotide| Crinone | Follistim | Gonal-F | Novarel | clomiphene citrate | Endometrin | Fyremadel | Ovidrel | chorionic gonadotropin | First-progesterone vaginal suppository | ganirelix acetate | Menopur | Pregnyl)

Ingrezza

Injectable Migraine Treatment (PREFERRED: Aimovig l Emgality) (NON-PREFERRED: Ajovy)

Inpefa

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

Insomnia Drugs (Belsomra | Dayvigo | quazepam (Doral) | Quviviq | ramelteon (Rozerem))

INSULINS (Admelog | Apidra vial or SoloSTAR | Basaglar | Fiasp | insulin aspart |insulin aspart protamine 70/30 | insulin degludec|insulin glargin-yfg| insulin glargine max solostar | insuline lispro | Levemir | Lyumjev/Kwikpen | NovoLIN 70/30 | NovoLIN N | NovoLIN R | NovoLOG vial or FlexPen | NovoLOG Mix 70/30 vial or FlexPen | Semglee)

Insulin Pumps

Irritable Bowel Disease (Mesalamine DR 800 mg | Dipentum | Budesonide ER 9mg | Uceris) (Non-Preferred Commercial)

Isturisa

Ivermectin (Stromectol) Tablets

Javygtor | Sapropterin Dihydrochloride (Kuvan)

Jesduvroq

Joenja

Juxtapid

Jynarque

Kalydeco

Kerendia

Kevzara

Kineret

Korlym

Koselugo

Lampit | benznidazole

Litfulo

Livalo | Zypitamag

Livmarli

Livtencity

Lodoco

Lonhala Magnair | Tudorza Pressair | Yupelri

Long-Acting Beta2 Agonist (LABA) and Inhaled Corticosteroid (ICS) Combination Products (AirDuo Digihaler | AirDuo RespiClick | budesonide-formoterol | Dulera | fluticasone-salmeterol | fluticasone furoate-vilanterol | Wixela Inhub)

Lupkynis

Marplan

Mifepristone

Mifepristone (Mifeprex) 200mg Tablet

Mulpleta

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

Myalept

Myfembree | Oriahnn

Mytesi (formerly FULYZAQ)

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

Natpara

Nayzilam | Valtoco

Neupro

Nexletol | Nexlizet

Nitazoxanide (Alinia)

Nocdurna

Non-Injectable Migraine Treatment (PREFERRED: Nurtec ODT | Qulipta) (Non-Preferred: Reyvow | Ubrelvy | Zavzpret)

Non-Preferred Inhaled Corticosteroid (Alvesco | ArmonAir Digihaler | Aasmanex | Flovent Diskus/HFA| fluticasone propionate Diskus/HFA)

Novarel | Pregnyl | Ovidrel | chorionic gonadotropin

Nucala - CRSWNP (Chronic Rhinosinusitis with Nasal Polyps) (Pharmacy)

Nucala SQ - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Pharmacy)

Nucala SQ - Hypereosinophilic Syndome (HES) (Pharmacy)

Nucala SQ - Severe Eosinophilic Asthma (SEA) (Pharmacy)

Nuedexta

Nulibry (Pharmacy)

Nuplazid

Ocaliva

Ocular Antihistamines (Alocril | Alomide | bepotastine besilate 1.5% (Bepreve) | Lastacaft | Zerviate)

Odactra House Dust Mite Allergen Extract

OFEV

Olumiant

Omvoh

Opfolda

Opioids

Opzelura

Oral Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Oral Proton Pump Inhibitors (PPI) Drugs (Non-Preferred) (dexlansoprazole | omeprazole/sodium bicarbonate | Voquezna)

Orally Administered Oncology Medications

Orencia SQ (Pharmacy)

Orfadin | Nityr | nitisinone

Orilissa

Orkambi

Osphena

Otezla

Otrexup | Rasuvo | Reditrex

Overactive Bladder Drugs (Gemtesa | Myrbetriq | fesoterodine (Toviaz))

Oxbryta

Oxervate

Oxlumo

Palforzia

Palynziq Injection

Pancreatic Enzymes (Pancreaze | Pertzye | Viokace)

Parathyroid Hormone Analogs (teriparatide (Forteo) | Tymlos | teriparatide)

Penciclovir (Denavir)

Pharmacy Benefit Oncology Medications

Pimecrolimus (Elidel)

Pirfenidone (Esbriet)

Pitavastatin (Livalo) | Zypitamag

Posaconazole DR (Noxafil) tablets | Noxafil DR suspension

Potassium Binders (Lokelma | Veltassa)

Pradaxa

Praluent | Repatha

Preferred Adalimumab Products (Cyltezo | Humira | Hyrimoz)

Pretomanid

Prevymis (Tablets) (Pharmacy benefit)

Procysbi

Promacta

Prophylaxis Hereditary Angiodema Drugs (Pharmacy) (Cinryze | Haegarda | Orladeyo | Takhzyro)

Pulmonary Arterial Hypertension Drugs (Pharmacy) (sildenafil 20mg | sildenafil oral suspension | tadalafil 20mg | Tadliq | ambrisentan | bosentan | Opsumit | Tracleer | Adempas | Orenitram | Tyvaso | Tyvaso DPI | Uptravi | Ventavis)

Pulmozyme

Purified Cortrophin Gel | HP Acthar Gel (Infantile Spasms)

Purified Cortrophin Gel | HP Acthar Gel (Myositis)

Purified Cortrophin Gel | HP Acthar Gel (Nephrotic Syndrome)

Purified Cortrophin Gel | HP Acthar Gel (Ocular Diseases)

Purified Cortrophin Gel | HP Acthar Gel (Other Indications)

Purified Cortrophin Gel | HP Acthar Gel (Sarcoidosis)

Purified Cortrophin Gel | HP Acthar Gel (Systemic Lupus Erythematosus)

Pyrimethamine (Daraprim)

Pyrukynd

Qelbree

Radicava ORS

Ragwitek

Ravicti

Rayaldee

Recombinant Growth Hormone (rhGH) (PREFERRED: Omnitrope | Norditropin) (NON-PREFERRED: Genotropin | Humatrope |Ngnela | Nutropin | Nutropin AQ | Saizen | Sogroya |Skytrofa | Zomacton)

Recorlev

Relyvrio

Revcovi (Pharmacy)

Rezurock

Rinvoq

Ruconest (Pharmacy)

Rukobia

Sabril | Vigadrone | vigabatrin| Vigpoder

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

Savaysa

Savella

Serostim

Seysara

SGLT2 (Brenzavvy| Invokana | Invokamet/XR | Qtern | Segluromet | Steglatro | Steguljan|Segluromet)

Siliq Injection (Pharmacy)

Simponi SQ (Pharmacy benefit only)

Sirturo

Skyclarys

Skyrizi - Crohn's Disease (CD) (Pharmacy)

Skyrizi - Plaque Psoriasis & Psoriatic Arthritis (PsO & PsA) (Pharmacy)

Sodium Oxbate Products (Lumryz | Sodium Oxbate oral solution | Xyrem | Xywav)

Sodium Phenylbutyrate Products (sodium phenylbutyrate (Buphenyl) | Olpruva | Pheburane)

Sohonos

Soliqua | Xultophy

Somatostatin Analog Drugs (Bynfezia | Mycapssa | Sandostatin LAR Depot | Signafor | Somavert) (Pharmacy)

Sotyktu

Spravato

Stelara - Crohn's Disease & Ulcerative Colitis (CD & UC) (Pharmacy)

Stelara - Plaque Psoriasis & Psoriatic Arthritis (PsO & PsA) (Pharmacy)

Stendra | Vardenafil (Levitra)

Strensiq

Sucraid

Sunlenca

Sunosi

Symdeko

Synagis (PASynagis)

Syndros Oral Solution

Taltz SQ

Tarpeyo

Tasimelteon (Hetlioz)

Tavalisse

Tavneos

Testosterone Replacement Therapy - TRT (Pharmacy) (PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution | Kyzatrex) (NON-PREFERRED - Androderm | Natesto | Vogelxo 1%)

Tetrabenazine (Xenazine)

Tezspire (Pharmacy)

Tiglutik

Tiopronin (Thiola) | Thiola EC

Tobi Podhaler

Tolvaptan (Samsca)

Topical Acne Drugs (PREFERRED: adapalene (generic Differin) | tretinoin (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel (Epiduo Forte) | Altreno | Aklief | Amzeeq | Azelex | clindamycin1.2%/benzoyl peroxide 2.5% (Acanya) | dapsone gel 5% (Aczone) | adapalene-benzoyl peroxide 0.1% (Fabior) | Retin-A Micro | tazarotene cream 0.1% (Tazorac) | tretinoin gel 0.05% (Atralin) | tretinoin microsphere (Retin-A Micro) | Winlevi)

Topical Antibiotics (Altabax | Xepi)

Topical Antifungals (Ertaczo | luliconazole (Luzu) | Mentax | naftifine (Naftin) | oxiconazole (Oxistat) | sulconazole (Exelderm))

Topical Corticosteroids (amcinonide 0.1% | betamethasone valerate 0.12% foam | calcipotriene/betamethasone | Capex Shampoo | clobetasol proprionate | clocortolone pivalate | Cordran Tape | dexoximetasone 0.05% and 0.25% | diflorasone 0.05% | fluocinonide 0.1% cream | flurandrenolide 0.05% | fluticasone 0.05% | Impoyz | Texacort | triamcinolone spray)

Topical Immunomodulators (Zyclara | imiquimod 3.75% packets/pump | Picato | Klisyri)

Topical Psoriasis Medications (Vtama | Zoryve)

Topical Rosacea Drugs (brimonidine (Mirvaso) | Rhofade | ivermectin (Soolantra) | Zilxi)

Tremfya

Trikafta

Tyvaso (PH-ILD)

Uloric

Upneeq

Vecamyl

Velsipity

Vemlidy

Veozah

Verquvo

Vijoice

Vivjoa

Vowst

Voxzogo

Vyleesi

Vyndaqel | Vyndamax

Vyvanse (Binge Eating Disorder)

Wakix

Weight Management Drugs (benzphetamine | Contrave | diethylpropion IR/ER | Lomaira | phendimetrazine IR | phentermine HCL | Qsymia | Saxenda | Xenical | Wegovy) Group Specific Benefit

Weight Management Drugs (Group Specific Benefit) (benzphetamine 50 mg | Contrave | diethylpropion IR/ER | Lomaira | phendimetrazine IR | phentermine HCL | Qsymia | Saxenda | Wegovy | Xenical | Zepbound)

Xadago

Xdemvy

Xeljanz | Xeljanz XR

Xenleta (Pharmacy)

Xifaxan

Xolair (Pharmacy)

Xphozah

Zeposia - Diagnosis: Ulcerative Colitis (UC)

Zokinvy

Zolmitriptan (Zomig) Nasal Spray

Zontivity

Zorbtive

Ztalmy

Zurzuvae

Zyflo | Zileuton ER

Medication Exception

Maximum Daily Dosage Limit Exceptions Request Form

Medication Exception Request Form (Commercial)

Pharmacy Medical Necessity Request Form

Prior Authorization

Compound Drugs

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

No Authorization Required List Of Procedure Codes

Inpatient Discharge Planning Resources

Notice of Medicare Non-Coverage Form

Notice of Medicare Non-Coverage Form (Spanish)
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