Pharmacy Forms and Prior Authorization Information

ePharm PA

• Online Prior Authorization System

Prior Authorization Forms - Drug-Specific

• Acne
• Angiotensin II Receptor Blockers (ARBs)
• Anti-Migraine Triptans
• Attention Deficit Hyperactivity Disorder
• Byetta (exenatide)
• HMG-CoA Reductase Inhibitors Lipitor
• Insomnia Medications
• Januvia (sitagliptin) and Janumet (sitagliptin-metformin)
• Leukotriene Inhibitors
• Long-Acting Narcotics
• Lyrica (pregabalin)
• Nonsedating Anti-Histamines
• NSAIDs, COX-2, Selective NSAIDs
• Ophthalmic Anti-Allergy
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
• Skeletal Muscle Relaxants
• Proton Pump Inhibitors
• Topical Antifungals
• Topical Corticosteroid Medications
• Topical Immunomodulators (Elidel & Protopic)
• Vaginal Anti-Infective Medications
• Xolair
• Xopenex
• Zelapar (selegiline orally disintegrating tablets)

Prior Authorization Form - Generic

This form is to be used by participating providers to request coverage for medications requiring prior authorization other than medications which are part of NHP's Specialty Pharmacy or Step Therapy program. Please fill out this form completely, including signature, and fax to MedMetrics Health Partners at 1-800-918-7542.

• Prior Authorization Form

Specialty Order Forms

Ordering instructions are included with forms.

• Curascript
• Medfusion Ascend Oncology
• Synagis