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Formulary

Covered drugs
Medicare Part D drug formulary
District of Columbia, Maryland, and Virginia (exchange) preferred drug list
Commonwealth of Virginia Medicaid and FAMIS Preferred Drug List
HMO formulary
Flexible Choice formulary
Prior Authorization
Maryland Health Choice Preferred Drug List
Request to review medications for addition/deletion to the formulary

Covered drugs

The Kaiser Permanente Mid-Atlantic States Region Drug Formulary (Preferred Drug) List includes those drugs that are preferred for use over other agents and comprise the Health Plan’s drug formulary.  This list is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy and Therapeutics Committee.  This committee is composed of Plan physicians, pharmacists and nurses.  The committee thoroughly reviews the medical literature and selects drugs for the formulary based on a number of factors including safety and effectives.  Plan providers (including contracted providers) should use the list to guide their decisions when they prescribe drugs.

Selection of generic medications is based on clinical effectiveness, safety, and therapeutic equivalence to a branded drug in accordance with all applicable federal, state and/or local statutes. If an FDA AB-rated approved therapeutically equivalent generic medication becomes available, the generic medication is added to formulary without Pharmacy and Therapeutic Committee review if the brand name medication is already on the formulary and has been reviewed in the past. Selected generic drugs such as hormonal therapy, narrow therapeutic index drugs, or non-formulary drugs may require a formal review by the Pharmacy and Therapeutic Committee before they are added to the drug formulary. The corresponding brand name drug is deleted from the drug formulary after review and approval by the Pharmacy and Therapeutic Committee.

Periodically a list of target drugs with potential for significant member and organizational cost savings if targeted for therapeutic conversion. The Clinical Pharmacy in collaboration with the MAPMG Physician Director of Pharmacy and Therapeutics Drug Utilization Management develops a standard process for therapeutic conversion for these agents. This process assures proper communication, implementation, and education of practitioners, pharmacists and KPMAS members about each drug conversion.

Upon evaluation, if a member qualifies for therapeutic conversion, an order is placed to the pharmacy. The member is informed of the therapeutic conversion and to call the pharmacy to have the prescription filled when they are ready to receive their medication. If the patient had an allergy or adverse reaction to the preferred drug, the preferred product is ineffective or patient refuses, this is documented in patient’s EMR and patient receives the preferred product.

Mandatory counseling by the dispensing pharmacist is in place to ensure patient education of the therapeutic conversion occurs at the time of dispensing.

Medications included on the Plan’s formulary are covered under the Member’s prescription drug benefit unless otherwise excluded by the Member’s specific group plan.  For additional information regarding a Member’s pharmacy benefits, please call Member Services at 1-800-777-7902.  Coverage for products not included on this list is granted when considered medically necessary by the member’s prescribing provider.

The cost of prescriptions may vary depending upon the type of drug and the member's particular pharmacy benefit. If members have questions about their pharmacy benefits, please refer them to the Evidence of Coverage document that they received at the beginning of this renewal year.

Copay information related to prescriptions drugs may be found on the following link: https://businessnet.kp.org/health/plans/mid/assistemployees/supportmaterials

To get updated information about the drugs included in the formulary, review the comprehensive listing of formulary drugs or contact Member Services.

Formulary for HMO members*(PDF)
Formulary for Flexible Choice members* (PDF)

Search our online drug formulary* (courtesy of Lexi-Comp) for HMO and Flexible Choice formulary.

Please note the following:

  • Drugs can be searched by brand or generic names.
  • Drugs that are not on the commercial formulary are not listed.
  • The Medicare Part D formulary may be found by clicking the Medicare Part D formulary below.

To request a paper copy of our formularies, please contact our Provider Relations department at 1-877-806-7470.

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Medicare Part D drug formulary

Our Kaiser Permanente’s Medicare Part D drug formulary is a list of the prescription drugs that are approved for coverage.

     Medicare Part D comprehensive formulary*

To request a paper copy of our formularies, please contact our Provider Relations department at 1-877-806-7470.

Medicare Part D-Provision of Notice

     Medicare Part D Benefit Coverage-Product Removal* (PDF)

District of Columbia, Maryland, and Virginia (exchange) preferred drug list

Download our District of Columbia, Maryland, and Virginia (exchange) preferred drug list.* (PDF)

HMO formulary

Download our HMO formulary.* (PDF)

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Flexible Choice formulary

Download our Flexible Choice formulary.* (PDF)

Prior Authorization

Prior Authorization Criteria

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization Criteria.* (PDF)

Prior Authorization Forms

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Abiraterone.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Actemra (tocilizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Acthar Gel (Repository Corticotropin Injection).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Adempas (Riociguat).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Adrenergics, Aromatic, Non_Catecholamine Agents.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Afinitor (Everolimus).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Afrezza (Insulin Regular).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Alecensa (alectinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Alunbrig (Brigatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Amitiza (lubiprostone).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Anakinra (Kineret).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Anti-epileptic agents.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Antihyperglycemic-Biguanides, Fortamet, Glumetza (Metformin HCL ER (MOD) & (OSM)).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) (PA) Form for Antihyperglycemics, DPP4 Inhibitors, DPP4 Combination (SGLT2, Metformin, Thiazolidinedione).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Antihyperglycemics, Incretin Mimetic (GLP-1 Receptor Agonist).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Antihyperglycemics, Insulin, Long Acting GLP-1 Receptor Agonists (Xultophy & Soliqua).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Aranesp (darbepoetin alfa).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Attention Deficit-Hyperactive (ADHD) & Naprcolepsy.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Balversa (Erdafitinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Basaglar Kwikpen, Semglee (Insulin Glargine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Bosulif (Bosutinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Braftovi (Encorafenib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Cabometyx (Cabozantinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Calquence (Acalabrutinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Caprelsa (Vandetanib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Cayston (aztreonam lysine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for certolizumab (Cimzia).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for CGRP Inhibitors-Injectable Emgality, Aimovig, Ajovy.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Cometriq (Cabozantinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Copiktra (Duvelisib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Cosentyx (secukinumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Cresemba (Isavuconazonium).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Crysvita (Burosumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Dalfampridine (Ampyra).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Dupixent (dupilumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Emflaza (deflazacort).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Emverm Chew (Mebendazole).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Enbrel (etanercept).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Endari (Glutamine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Epidiolex (cannabidiol).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Erivedge (Vismodegib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Erleada (Apalutamide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Esbriet (pirfenidone).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Fasenra (benralizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Firdapse (amifampridine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Gilotrif (Afatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Givlaari (Givosiran Sodium).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Gleevec (Imatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for golimumab (Simponi).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Hemlibra (Emicizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Hepatitis C Antivirals.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ibrance (palbociclib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Iclusig (Ponatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Idhifa (Enasidenib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ilaris (canakinumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Imbruvica (ibrutinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Imcivree (Setmelanotide Acetate).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Inlyta (Axitinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Inrebic (Febratinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Insulins.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Iressa (Gefitinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Jakafi (Ruxolitinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Jynarque (tolvaptan).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Kalydeco (Ivacaftor).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Kesimpta (Ofatumumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Kevzara (sarilumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Kisqali (Ribociclib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Lenvima (Lenvatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Letairis (Ambrisentan) Tracleer (Bosentan) Opsumit (Macitentan).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Levemir, Tresiba & Toujeo.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Linzess (linaclotide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Lonsurf (Trifluridine_Tipiracil).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Lorbrena (Lorlatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Lynparza (Olaparib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Mekinist (Trametinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Mektovi (Binimetinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Methotrexate (Rasuvo, Otrexup).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Mircera.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Motegrity (prucalopride).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Movantik (naloxegol).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Multiple Sclerosis Highly effective DMTs.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Multiple Sclerosis Modestly Effective DMTs.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Myalept (Metreleptin).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Myrbetriq (Mirabegron).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Nerlynx (Neratinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Nexavar (sorafenib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ninlaro (ixazomib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Nubeqa (Darolutamide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Nucala (mepolizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Nurtec (Rimegepant) Reyvow (Lasmiditan).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ocaliva (obeticholic acid).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ofev (nintedanib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Orencia (abatacept).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Orkambi (Lumacaftor-Ivacaftor).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Otezla (apremilast).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Oxbryta (Voxelotor).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Palynziq (Pegvaliase).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Piqray (Alpelisib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Pomalyst (pomalidomide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Reblozyl (Luspatercept).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Relistor (methylnaltrexone).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Retacrit (epoetin alfa-epbx).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Revlimid (lenalidomide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Rinvoq, Olumiant.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Rubraca (Rucaparib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ruzurgi (amifampridine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Rydapt (Midostaurin).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for SGLT2 Inhibitors, SGLT2 Inhibitors-Biguanides.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Sprycel (dasatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Stelara (ustekinumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Stivarga (Regorafenib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Sunosi (Solriamfetol).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Sutent (Sunitinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Sylatron (Peginterferon).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Symdeko (Tezacaftor-Ivacaftor).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Symproic (naldemedine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tagrisso (osimertinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Talzenna (Talazoparib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tarceva (Erlotinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Targretin (Bexarotene).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tasigna (Nilotinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tegsedi (inotersen).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tremfya, Skyrizi, Taltz, Siliq , Ilumya.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Trikafta (Elexacaftor-Tezacaftor-Ivacaftor).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Trulance (plecanatide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tykerb (Lapatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ubrelvy (urbrogepant).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Uptravi (Selexipag) Tyvaso (Treprostinil) Orenitram (Treprostinil-Diolamine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Verzenio (Abemaciclib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Viberzi (eluxadoline).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Vitrakvi (Larotrectinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Vizimpro (Dacomitinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Votrient (pazopanib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Vyndaqel (Tafamidis Meglumine) Vyndamax (Tafamidis).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Wakix (Pitolisant).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xalkori (Crizotinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xeljanz (tofacitinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xifaxan (Rifaximin).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xolair (omalizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xospata (Gilteritinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xtandi (enzalutamide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xyrem (sodium oxybate).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Zejula (Niraparib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Zolinza (Vorinostat).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Zydelig (Idelalisib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Zykadia (Ceritinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form Humira (adalimubab).* (PDF)

Download the HMO/Flexible choice/District of Columbia/Maryland and Virginia (exchange) Prior Authorization (PA) Form for Epinephrine Anaphylaxis Auvi-Q.* (PDF)

Download the HMO/Flexible choice/District of Columbia/Maryland and Virginia (exchange) Prior Authorization for PCSK9 inhibitor drugs.* (PDF)

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Commonwealth of Virginia Medicaid and FAMIS Preferred Drug List

Download our Preferred Drug List for Virginia Medicaid and FAMIS members.* (PDF)

Commonwealth of Virginia Medicaid 90 days Maintenance Drug List

A new policy allows coverage of a maximum of a 90-day supply of many maintenance drugs, effective 10/1/2021. The list of eligible maintenance drugs has been developed to include many chronic medications on the Commonwealth of Virginia Medicaid and FAMIS Preferred drug list. Members will be eligible for this policy after receiving two 34-day or shorter fills of drugs on this list. This new maintenance list is not all-inclusive. If your medication is not on the maintenance list, you may receive a maximum 34-day supply of your prescriptions.

Prior Authorization Criteria

Download the Virginia Medicaid-FAMIS Prior Authorization and Step Therapy Criteria.* (PDF)

Prior Authorization Forms

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Afinitor (Everolimus).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Alunbrig (Brigatinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Balversa (Erdafitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Bosulif (Bosutinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Braftovi (Encorafenib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Cabometyx (Cabozantinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Calquence (Acalabrutinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Caprelsa (Vandetanib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Cometriq (Cabozantinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Copiktra (Duvelisib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Crysvita (Burosumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Emverm Chew (Mebendazole).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Endari (Glutamine).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Erivedge (Vismodegib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Erleada (Apalutamide).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Gilotrif (Afatinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Givlaari (Givosiran Sodium).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Gleevec (Imatinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Hemlibra (Emicizumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Iclusig (Ponatinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for IIdhifa (Enasidenib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Inlyta (Axitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Inrebic (Febratinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Iressa (Gefitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Jakafi (Ruxolitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Kalydeco (Ivacaftor).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Kisqali (Ribociclib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Lenvima (Lenvatinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Lonsurf (Trifluridine_Tipiracil).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Lorbrena (Lorlatinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Lynparza (Olaparib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Mekinist (Trametinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Mektovi (Binimetinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Myalept (Metreleptin).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Nerlynx (Neratinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Nubeqa (Darolutamide).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Orkambi (Lumacaftor-Ivacaftor).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Oxbryta (Voxelotor).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Palynziq (Pegvaliase).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Piqray (Alpelisib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Reblozyl (Luspatercept).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Rubraca (Rucaparib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Rydapt (Midostaurin).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Stivarga (Regorafenib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Sutent (Sunitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Sylatron (Peginterferon).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Symdeko (Tezacaftor-Ivacaftor).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Talzenna (Talazoparib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Tarceva (Erlotinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Targretin (Bexarotene).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Tasigna (Nilotinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Trikafta (Elexacaftor-Tezacaftor-Ivacaftor).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Tykerb (Lapatinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Verzenio (Abemaciclib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Vitrakvi (Larotrectinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Vizimpro (Dacomitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Vyndaqel (Tafamidis Meglumine) Vyndamax (Tafamidis).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Xalkori (Crizotinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Xospata (Gilteritinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Zejula (Niraparib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Zolinza (Vorinostat).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Zydelig (Idelalisib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Zykadia (Ceritinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Actemra (tocilizumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Acthar Gel (Repository Corticotropin Injection).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Anakinra (Kineret).* (PDF)

Download the Virginia Medicaid FAMIS Prior Authorization (PA) Form for Arcalyst (rilonacept).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Aubagio (Teriflunomide).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for certolizumab (Cimzia).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Cosentyx (secukinumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Dalfampridine (Ampyra).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Emflaza (deflazacort).* (PDF)

Download the Virginia Medicaid FAMIS Prior Authorization (PA) Form for Enspryng (satralizumab-mwge).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Epidiolex (cannabidiol).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Esbriet (pirfenidone).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Fasenra (benralizumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Firdapse (amifampridine).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for golimumab (Simponi).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Ilaris (canakinumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Ilumya (tildrakizumab-asmn).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Jynarque (tolvaptan).* (PDF)

Download the Virginia Medicaid FAMIS Prior Authorization (PA) Form for Kesimpta (ofatumumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Kevzara (sarilumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Mayzent, Mavenclad and Zeposia (Multiple-Sclerosis).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Nucala (mepolizumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Ofev (nintedanib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Olumiant (baricitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Orencia (abatacept).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Otezla (apremilast).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Otrexup (Methotrexate).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Plegridy (Peginterferon Beta-1a).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Rasuvo (Methotrexate).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Rivoq (Upadacitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Ruzurgi (amifampridine).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Siliq (brodalumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Skyrizi (risankizumab-rzaa).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Stelara (ustekinumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Taltz (ixekizumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Tegsedi (inotersen).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Tremfya (guselkumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Vumerity (Diroximel Fumarate).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Xeljanz (tofacitinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Xolair (omalizumab).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Xyrem (sodium oxybate).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Abiraterone.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Alecensa (alectinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Androgenic Agent (Topical Testosterone).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Antibiotics, Inhaled (Tobi Podhaler) ST.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Anticonvulsant.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Antiemetic Agents (Cannabinoid Derivatives).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Antiobesity Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Antipsychotic Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Beta Adrenergics & Combinations.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Dipeptidyl Peptidase IV (DPP-IV) Inhibitors.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Gastrointestinal (GI) Motility Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Growth Hormones.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Hepatitis C Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Hereditary Angioedema (HAE) Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Ibrance (palbociclib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Imbruvica (ibrutinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Immunomodulators (Atopic Dermatitis).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Nexavar (sorafenib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Ninlaro (ixazomib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form SA_LA_Methadone Opioids.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Opioid-Benzodiazepine Concurrent Use.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form Oral Opioid Dependence .* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Pancreatic Enzymes.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Pomalyst (pomalidomide).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Proprotein Convertase Subtilisin Kexin Type-9 PCSK9 and ACL (Inhibitors).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Pulmonary Arterial Hypertension (PAH) Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Revlimid (lenalidomide).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Sodium Glucose Cotransporter-2 (SGLT-2) Inhibitors.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Sprycel (dasatinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) for Stimulants (ADHD).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Tagrisso (osimertinib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Topical Acne.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Votrient (pazopanib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Xtandi (enzalutamide).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) for AntiMigraine Calcitonin Gene Related Peptide Antagonist.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Interleukin Inhibitors (Dupixent).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Epinephrine Anaphylaxis Auvi-Q.* (PDF)

Oral Opioid Dependance
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Maryland Health Choice Preferred Drug List

Download our Maryland Health Choice Preferred Drug List.* (PDF)

Prior Authorization Criteria

Download the Maryland Health Choice Prior Authorization (PA) Criteria.* (PDF)

Prior Authorization Forms

Download the Maryland Health Choice Prior Authorization (PA) Form for Actemra (tocilizumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Acthar Gel (Repository Corticotropin Injection).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Adempas (Riociguat).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Afinitor (Everolimus).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Afrezza (Insulin Regular).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Alunbrig (Brigatinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Amitiza (lubiprostone).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Anakinra (Kineret).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Antihyperglycemic-Biguanides, Fortamet, Glumetza (Metformin HCL ER (MOD) and Metformin HCL ER (OSM)).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Aranesp (darbepoetin alfa).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Balversa (Erdafitinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Basaglar Kwikpen, Semglee (Insulin Glargine).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Bosulif (Bosutinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Braftovi (Encorafenib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Cabometyx (Cabozantinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Calquence (Acalabrutinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Caprelsa (Vandetanib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Cayston (aztreonam lysine).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for certolizumab (Cimzia).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for CGRP Inhibitors-Injectable Emgality, Aimovig, Ajovy.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Cometriq (Cabozantinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Copiktra (Duvelisib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Cosentyx (secukinumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Cresemba (Isavuconazonium).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Crysvita (Burosumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Dalfampridine (Ampyra).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Dupixent (dupilumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Emflaza (deflazacort).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Emverm Chew (Mebendazole).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Enbrel (etanercept).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Endari (Glutamine).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Erivedge (Vismodegib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Erleada (Apalutamide).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Esbriet (pirfenidone).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Fasenra (benralizumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Firdapse (amifampridine).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Gilotrif (Afatinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Givlaari (Givosiran Sodium).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Gleevec (Imatinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for golimumab (Simponi).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Hemlibra (Emicizumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form Humira (adalimubab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Iclusig (Ponatinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Idhifa (Enasidenib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Ilaris (canakinumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Inlyta (Axitinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Inrebic (Febratinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Insulins.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Iressa (Gefitinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Jakafi (Ruxolitinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Jynarque (tolvaptan).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Kalydeco (Ivacaftor).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Kesimpta (Ofatumumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Kevzara (sarilumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Kisqali (Ribociclib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Lenvima (Lenvatinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Letairis (Ambrisentan) Tracleer (Bosentan) Opsumit (Macitentan).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Levemir, Tresiba & Toujeo.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Linzess (linaclotide).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Lonsurf (Trifluridine_Tipiracil).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Lorbrena (Lorlatinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Lynparza (Olaparib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Mekinist (Trametinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Mektovi (Binimetinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Methotrexate (Rasuvo, Otrexup).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Mircera.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Motegrity (prucalopride).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Movantik (naloxegol).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Multiple Sclerosis Nonpreferred Highly effective DMTs.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Multiple Sclerosis Nonpreferred Modestly Effective DMTs.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Myalept (Metreleptin).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Myrbetriq (Mirabegron).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Nerlynx (Neratinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Nubeqa (Darolutamide).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Nucala (mepolizumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Nurtec (Rimegepant) Reyvow (Lasmiditan).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Ocaliva (obeticholic acid).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Ofev (nintedanib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Orencia (abatacept).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Orkambi (Lumacaftor-Ivacaftor).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Otezla (apremilast).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Oxbryta (Voxelotor).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Palynziq (Pegvaliase).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Piqray (Alpelisib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Reblozyl (Luspatercept).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Relistor (methylnaltrexone).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Retacrit (epoetin alfa-epbx).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Rinvoq, Olumiant.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Rubraca (Rucaparib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Ruzurgi (amifampridine).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Rydapt (Midostaurin).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Stelara (ustekinumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Stivarga (Regorafenib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Sutent (Sunitinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Sylatron (Peginterferon).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Symdeko (Tezacaftor-Ivacaftor).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Symproic (naldemedine).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Talzenna (Talazoparib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Tarceva (Erlotinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Targretin (Bexarotene).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Tasigna (Nilotinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Tegsedi (inotersen).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Tremfya, Skyrizi, Taltz, Siliq , Ilumya.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Trikafta (Elexacaftor-Tezacaftor-Ivacaftor).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Trulance (plecanatide).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Tykerb (Lapatinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Ubrelvy (urbrogepant).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Uptravi (Selexipag) Tyvaso (Treprostinil) Orenitram (Treprostinil-Diolamine).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Verzenio (Abemaciclib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Viberzi (eluxadoline).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Vitrakvi (Larotrectinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Vizimpro (Dacomitinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Vyndaqel (Tafamidis Meglumine) Vyndamax (Tafamidis).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Xalkori (Crizotinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Xeljanz (tofacitinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Xifaxan (Rifaximin).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Xolair (omalizumab).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Xospata (Gilteritinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Xyrem (sodium oxybate).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Zejula (Niraparib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Zolinza (Vorinostat).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Zydelig (Idelalisib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Zykadia (Ceritinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Abiraterone.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Alecensa (alectinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Ibrance (palbociclib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Imbruvica (ibrutinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Nexavar (sorafenib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Ninlaro (ixazomib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Pomalyst (pomalidomide).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Revlimid (lenalidomide).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Sprycel (dasatinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Tagrisso (osimertinib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Votrient (pazopanib).* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Xtandi (enzalutamide).* (PDF)

Download the Prior Authorization (PA) Form for SGLT-2 Inhibitors.* (PDF)

Download the Maryland Health Choice Prior Authorization for PCSK9 inhibitor drugs.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Opioids.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Forms for Glucagon-like peptide-1 (GLP1) Agonists.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Forms for Dipeptidyl peptidase-4 (DPP4) Inhibitors.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Growth Hormones.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Hepatitis C Therapy.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Epinephrine Anaphylaxis Auvi-Q.* (PDF)

Request to review medications for addition/deletion to the formulary

The Kaiser Permanente Mid-Atlantic State Pharmacy and Therapeutics Committee will consider requests from Kaiser Permanente members, physicians, or pharmacists as well as network-affiliated providers to review medications for addition to, or deletion from, the Health Plan’s drug formulary. You can download a form to submit this request.* (PDF)

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