Drug authorization forms list

Use the right form for the patient’s Priority Health plan:

Traditional: Most employer group plan members
Optimized: MyPriority individual plans and some employer group plans (member ID card will show Optimized RX: Yes)
Medicaid: Medicaid and Healthy Michigan plan members
Medicare: Medicare Advantage plan members and employer-sponsored Medicare plans such as MPSERS

Non-Medicare forms

Dispense as Written (DAW) (05/2018)

Michigan PA Request Form for Prescription Drugs (11/2015)
Fax to Priority Health at 877.974.4411

Non-Covered Medication (01/2018)

Quantity Limit Exception request form (09/2017)

Medicare forms

Medicare Part B Prior Authorization Form (05/2018)

Medicare Part D Coverage Determination Request Form (12/2011)

Medicare prescription drug request for redetermination (appeal) form (11/2011)

Hospice/Part D drug prior authorization form (05/2018)

Drug-specific authorization forms

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 

A

Abilify® form Medicare only (01/2018)
Abstral® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Acitretin® form Medicaid only (02/2018)
Actemra® forms Traditional & Optimized (03/2018) or Medicare (01/2018)
Acthar® forms Traditional & Optimized (03/2018)
Actimmune® form Medicare only (03/2018)
Actiq® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Adcetris® form Traditional & Optimized, & Medicaid only (01/2018)
Adcirca® forms Traditional & Optimized (02/2018) or Medicaid (02/2018) or Medicare (07/2017)
Adempas® forms Traditional & Optimized (03/2018) or Medicaid (02/2018) or Medicare (01/2018)
Adlyxin® form Optimized (07/2017)
Afinitor® forms Traditional & Optimized (05/2018) or Medicaid (05/2018) or Medicare (03/2018)
Aldurazyme® forms Traditional, Optimized, & Medicaid (03/2018)
Alecensa® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Aliqopa® forms Traditional & Optimized (01/2018) or Medicaid (01/2018)
Alogliptin forms Optimized (05/2018) or Medicaid (02/2018)
Alosetron form Traditional & Optimized (09/2017)
Alunbrig® forms Traditional & Optimized (07/2017) or Medicare (01/2018)
Amitriptyline form Medicare only (01/2018)
Amnesteem® form Traditional & Optimized (05/2018)
Ampyra® forms Traditional (02/2018) or Optimized (02/2018) or Medicaid (02/2018) or Medicare (11/2017)
Anzemet®  Medicare Part B vs. Part D determination (09/2017)
Aptiom® form Traditional & Optimized (01/2018)
Aralast NP forms Traditional, Optimized, & Medicaid (03/2018) or Medicare (03/2018)
Aranesp® forms Medicaid (02/2018) or Medicare Part B vs. Part D determination (09/2017)
Aripiprazole form Medicare only (01/2018)
Armodafinil forms Traditional & Optimized (09/2017) or Medicare (11/2017)
Arymo™ ER form Traditional & Optimized (05/2018)
Arzerra® forms Traditional, Optimized, & Medicaid (11/2017) or Medicare (01/2018)
Aubagio® form Optimized (05/2018)
Auryxia ™ form Traditional & Optimized (01/2018)
Austedo™ forms Traditional & Optimized (01/2018) or Medicare (03/2018)
Aveed® forms Traditional & Optimized (05/2018) or Medicare (11/2017)
Avonex® forms Optimized (05/2018) or Medicaid (02/2018)
Azathioprine form Medicare Part B vs. Part D determination only (11/2017)

B

Banzel® forms Traditional & Optimized (09/2017) or Medicare (09/2017)
Bavencio® form Traditional & Optimized (03/2018)
Belbuca™ form Optimized (09/2017)
Beleodaq® forms Traditional, Optimized, & Medicaid (09/2017) or Medicare (09/2017)
Benlysta® form Traditional, Optimized, & Medicaid only (03/2018)
Berinert® forms Traditional & Optimized (01/2018) or Medicare (01/2017)
Besponsa® form Traditional, Optimized, & Medicaid only (11/2017)
Betaseron® form Optimized (05/2018)
Bethkis® forms Traditional & Optimized (02/2018) or Medicaid (02/2018)
Blincyto® forms Traditional, Optimized, & Medicaid (05/2018) or Medicare (05/2018)
Boniva® form Traditional & Optimized (01/2018)
Bosulif® forms Traditional & Optimized (03/2018) or Medicare (05/2018)
Botulinum toxin forms Traditional, Optimized, & Medicaid (04/2018) or Medicare (05/2018)
Brineura™ form Traditional & Optimized (07/2017)
Briviact® form Traditional & Optimized (03/2018)
Buphenyl® form Traditional & Optimized (03/2018)
Buprenorphine and naloxone form Medicare only (01/2018)
Buprenorphine transdermal patch form Optimized (09/2017)
Bydureon® form Optimized (11/2017)
Byetta® form Optimized (11/2017)

C

Cabometyx™ forms Traditional & Optimized (01/2018) or Medicare (11/2017)
Calquence® forms  Traditional & Optimized (01/2018) or Medicare (03/2018)
Caprelsa® forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Carbaglu® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Cayston® forms Traditional (02/2018) or Optimized (05/2018) or Medicaid (02/2018) or Medicare (01/2018)
Cerezyme® form Traditional, Optimized, & Medicaid (05/2018)
Cholbam™ forms Traditional & Optimized (07/2017) or Medicare (01/2018)
Chorionic gonadotropin form Medicare only (01/2018)
Cialis® form Medicare only  (01/2018)
Cimzia® forms Tradtional & Optimized (03/2018) or Medicare (03/2017)
Cinqair® forms Traditional, Optimized, & Medicaid (01/2018) or Medicare (07/2017)
Cinryze® form Traditional & Optimized (09/2017)
Claravis®  forms Traditional & Optimized (05/2018) or Medicaid (03/2018)
Cometriq™ forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Cosentyx® forms Traditional & Optimized (03/2018) or Medicare (01/2018)
Cotellic® forms Traditional & Optimized (01/2018) or Medicare (01/2018)
Cresemba® form Traditional & Optimized (05/2018)
Crinone® form Medicare only (01/2018)
Cyramza® form Traditional, Optimized, & Medicaid (07/2017)

D

Daklinza® forms Traditional (11/2017) or Optimized (11/2017) or Medicare (01/2018)
Daliresp® forms Traditional & Optimized (09/2017) or Medicare (09/2017)
Dalvance® form Traditional & Optimized (09/2016)
Daraprim® form Medicaid only (02/2018)
Depen® form Traditional & Optimized (03/2018)
Desmopressin form Medicaid only (03/2018)
Diabetic test strips form Medicare Part B only (01/2018)
Diclofenac 3% gel form Medicaid only (04/2018)
Digitek® form Medicare only (05/2018)
Digoxin form Medicare only (05/2018)
Digox® form Medicare only (05/2018)
Dronabinol forms Medicaid (03/2018) or Medicare Part B vs. Part D determination (07/2017)
Duopa® form Traditional & Optimized (03/2018)
Dupixent® forms Traditional & Optimized (07/2017) or Medicare (03/2018)

E

Elaprase® form Traditional, Optimized, & Medicaid (05/2018)
Elavil® form Medicare only (01/2016)
Elelyso® form Traditional, Optimized, & Medicaid (05/2018)
Embeda® form Traditional & Optimized (05/2018)
Emend® form Medicare Part B vs Part D determination (07/2017)
Enbrel® forms Traditional & Optimized (03/2018) or Medicaid (02/2018) or Medicare (09/2017)
Entresto® forms Traditional & Optimized (02/2018)
Entyvio® form Traditional, Optimized, & Medicaid (09/2017)
Epclusa® forms Traditional (11/2017) or Optimized (11/2017) or Medicare (06/2017)
Epogen® forms Medicaid (02/2018) or Medicare Part B vs. Part D determination (09/2017)
Erbitux® forms Traditional, Optimized, & Medicaid (09/2017) or Medicare (09/2017)
Erivedge® forms Traditional, Optimized, & Medicaid (07/2017) or Medicare (09/2017)
Erleada™ form Medicare only (05/2018)
Erwinaze® form Traditional, Optimized, & Medicaid (07/2017)
Esbriet® forms Traditional & Optimized (01/2017) or Medicare (01/2018)
Eszopiclone form Medicare only (01/2018)
Extavia® form Optimized (05/2018)
Eylea® form Traditional, Optimized, & Medicaid (11/2017)

F

Fabrazyme® form Traditional, Optimized, & Medicaid (01/2018)
Farxiga® form Optimized (01/2018)
Farydak™ forms Traditional, Optimized, & Medicaid (05/2018) or Medicare (05/2018)
Fasenra™ forms Traditional, Optimized, & Medicaid  (01/2018) or Medicare (03/2018)
Fentanyl citrate lozenge forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Fentanyl transdermal patch form Optimized (09/2017)
Fentora® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Firazyr® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Flector™ form Medicare only (05/2018)
Flolan® form Traditional, Optimized, & Medicaid (07/2017)
Fluorouracil form Medicaid only (04/2018)
Forteo® forms Traditional & Optimized (09/2017) or Medicaid (03/2018) or Medicare (01/2017)

G

Gattex® forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Gazyva® forms Traditional & Optimized (01/2018) or Medicare (11/2016)
Gilenya® form Medicaid only (02/2018)
Gilotrif® forms Traditional & Optimized (03/2018) or Medicare (11/2017)
Glassia® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Glatopa /Glatiramer acetate forms Optimized (10/2017) or Medicaid (02/2018)
Gleevec® forms Traditional & Optimized (07/2017)
Glyxambi® form Optimized (01/2018)
Gralise® form Traditional & Optimized (07/2017)
Granisetron form Medicare Part B vs. Part D determination (09/2016)
Granix® form Medicaid only (02/2018)

H

Haegarda® forms Traditional & Optimized (09/2017) or Medicare (09/2017)
Harvoni®
 forms Traditional (05/2018) or Optimized (05/2018) or Medicare (01/2018)
Hemlibra® form Traditional & Optimized (01/2018)
Hetlioz® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Human growth hormone forms Traditional (01/2018) or Optimized (01/2018) or Medicaid (02/2018) or Medicare (11/2017)
Humira® forms Traditional & Optimized (03/2018) or Medicaid (05/2018) or Medicare (03/2018)
Hydromorphone ER form Optimized (09/2017)
Hydroxprogesterone Caproate form Traditional, Optimized, & Medicaid (05/2018)
Hysingla ER® forms Traditional & Optimized (05/2018) or Medicare (03/2018)

I

Ibrance® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Iclusig® forms Traditional and Optimized (07/2017) or Medicare (07/2017)
Idhifa™ form Medicare only (03/2018)
Ilaris® forms Traditional and Optimized (11/2017) or Medicare (11/2017)
Imbruvica® forms Traditional and Optimized (03/2018) or Medicare (03/2018)
Imfinzi™ form Traditional, Optimized, & Medicaid (03/2018)
Imipramine form Medicare only (11/2017)
Imlygic® forms Traditional, Optimized, & Medicaid (01/2018) or Medicare (01/2017)
Immune globulin (IVIG, SCIG) forms Traditional, Optimized, & Medicaid (03/2018) or Medicare (03/2018)
Immunosuppressive drugs (oral) form Medicare Part B vs. Part D determination (09/2017)
Impavido® form Traditional, Optimized, & Medicaid (07/2017)
Increlex® forms Traditional and Optimized (02/2018) or Medicaid (02/2018)
Inflectra™ forms Traditional, Optimized, & Medicaid (01/2018) or Medicare (01/2018)
Ingrezza® forms Traditional and Optimized (01/2018) and Medicare (07/2017)
Inhalation solutions used with a nebulizer form Medicare Part B vs. Part D determination (09/2017)
Inlyta® forms Traditional and Optimized (07/2017) or Medicare (07/2017)
Intrarosa™ form Traditional and Optimized (09/2017)
Invokamet®, Invokana® forms Optimized (01/2018) or Medicaid (02/2018)
Iressa® forms Traditional and Optimized (09/2017) or Medicare (07/2017)
Istodax® form Traditional, Optimized, & Medicaid (04/2018)
IVIG forms Traditional, Optimized, & Medicaid (03/2018) or Medicare (03/2018)

J

Jakafi® forms Traditional, Optimized, & Medicaid (07/2017) or Medicare (07/2017)
Janumet®/Janumet XR®/Januvia®/Jentadueto® forms Optimized (03/2017) or Medicaid (02/2018)
Jardiance® forms Optimized (01/2018) or Medicaid (02/2018)
Jevtana® forms Traditional, Optimized, & Medicaid (11/2017) or Medicare (11/2016)
Juxtapid® forms Traditional and Optimized (05/2018) or Medicare (05/2018)

K

Kadcyla forms Traditional, Optimized, & Medicaid (05/2018) or Medicare (05/2018)
Kalbitor® forms Traditional and Optimized (01/2018) or Medicare (01/2017)
Kalydeco® forms Traditional (03/2018) or Optimized (01/2018) or Medicare (01/2018)
Kanuma® form Traditional, Optimized, & Medicaid (03/2018)
Keveyis® form Traditional & Optimized (11/2017)
Kevzara® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Keytruda® forms Traditional, Optimized, & Medicaid (11/2017) or Medicare (11/2016)
Kineret® forms Traditional & Optimized (03/2018) or Medicare (09/2016)
Kisqali® forms Traditional & Optimized (05/2018) or Medicare (06/2017)
Kitabis Pak™ forms Traditional & Optimized (02/2018) or Medicaid (02/2018) or Medicare (11/2016)
Kombiglyze® XR form Optimized (03/2017)
Korlym® form Traditional & Optimized (05/2018)
Krystexxa® form Traditional, Optimized, & Medicaid (03/2018)
Kymriah™ form Traditional & Optimized (01/2018)
Kynamro® forms Traditional, Optimized, & Medicaid (05/2018) or Medicare (03/2018)

L

Lartruvo  Traditional, Optimized, & Medicaid (03/2018)
Lazanda® forms Traditional & Optimized (11/2017) or Medicare (05/2018)
Lemtrada® Medicare only (01/2017)
Lenvima® forms Traditional & Optimized (05/2018) or Medicare (05/2018)
Letairis®  Traditional & Optimized (02/2018) or Medicaid (02/2018)
Lidocaine 5% patch forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Linezolid
Traditional & Optimized (02/2018) or Medicaid (02/2018) or Medicare (02/2018)
Lonsurf®
 forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Lotronex®  Traditional & Optimized (10/2017)
Lovaza® Traditional & Optimized (02/2018) or Medicaid (02/2018)
Lucentis® Traditional, Optimized, & Medicaid (05/2018)
LuxturnaTraditional & Optimized (03/2018)
Lynparza® forms Traditional, Optimized, & Medicaid (03/2018) or Medicare (03/2017)

M

Macugen® Traditional, Optimized, & Medicaid (01/2018)
Makena® Traditional, Optimized, & Medicaid (05/2018)
Marqibo® Traditional, Optimized, & Medicaid (11/2017)
Matulane® forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Mavyret™ forms Traditional (11/2017) or Optimized (11/2017) or Medicare (03/2018)
Mekinist® forms Traditional & Optimized (09/2017) or Medicare (01/2017)
Methadone Optimized (09/2017)
Miglustat Traditional & Optimized (05/2018)
Mirvaso® Medicare only (01/2018)
Modafinil form Medicare (03/2018)
Morphine Optimized (09/2017)
Myalept® forms Traditional & Optimized (01/2018) or Medicare (01/2017)
Mylotarg® Traditonal, Optimized, & Medicaid (03/2018)
Myorisan™ Traditional & Optimized (05/2018)

N

Naglazyme® Traditional, Optimized, & Medicaid (05/2018)
Naproxen suspension Medicaid only (04/2018)
Natpara® forms Traditional & Optimized (07/2017) or Medicare (01/2018)
Nebupent® Medicare only (01/2018)
Nerlynx® forms Traditional & Optimized (03/2018) or Medicare (09/2017)
Neupogen® forms Medicaid (02/2018) or Medicare (09/2017)
Nexavar® forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Ninlaro® Traditional & Optimized (05/2018)
Nityr® Traditional & Optimized (11/2017)
Noxafil® Traditional & Optimized (05/2018)
Nplate® forms Traditional & Optimized (07/2017) or Medicare (05/2018)
Nucala® forms Traditional & Optimized (03/2018) or Medicare Part B (07/2017)
Nucynta® ER Optimized (05/2018)
Nuedexta® Traditional & Optimized (11/2017)
Nulojix® forms Traditional, Optimized, & Medicaid (11/2017) or Medicare (11/2016)
Nuplazid™ forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Nuvigil® forms Traditional & Optimized (11/2017) 

O

Ocaliva™ form Traditional & Optimized (09/2017)
Ocrevus™ form Traditional, Optimized, & Medicaid only (01/2018)
Octreotide form Medicaid only (02/2018)
Odomzo® form Traditional & Optimized (11/2017)
Ofev® forms Traditional & Optimized (01/2018) or Medicare (01/2017)
Ondansetron form Medicare Part B vs. Part D determination (11/2017)
Onglyza® form Optimized (05/2018)
Onivyde® forms Traditional, Optimized, & Medicaid (01/2018) or Medicare (05/2018)
Opdivo® forms Traditional, Optimized, & Medicaid (03/2018) or Medicare (09/2016)
Opioid drug exceptions form Traditional, Optimized, & Medicaid (11/2017)
Opsumit® forms Traditional & Optimized (01/2017) or Medicare (01/2017)
Oral oncology drugs form Medicaid only (02/2018)
Orencia® forms Traditional & Optimized (02/2018) or Medicare (01/2018)
Orenitram® ER forms Traditional & Optimized (05/2018) or Medicare (01/2018)
Orfadin® forms Traditional & Optimized (03/2018) or Medicare (07/2017)
Orkambi® forms Traditional (09/2017) or Optimized (05/2017) or Medicare (09/2017)
Osphena® form Traditional & Optimized (05/2018)
Otezla® forms Traditional & Optimized (03/2018) or Medicaid (02/2018) or Medicare (05/2017)
Oxtellar™ XR form Traditional & Optimized (07/2017)
Oxycodone ER form Optimized (09/2017)
OxyContin® form Optimized (09/2017)
Oxymorphone ER form Optimized (09/2017)

P

Parsabiv™  form Traditional & Optimized (01/2018)
Perjeta®
form Traditional, Optimized, & Medicaid only (11/2017)
Phenobarbital form Medicare only (01/2017)
Phenoxybenzamine form Traditional & Optimized (04/2018)
Plegridy™  form Optimized (05/2018)
Pomalyst® forms Traditional, Optimized, & Medicaid (05/2018) or Medicare (01/2018)
Praluent® forms Traditional & Optimized (03/2018)
Prevymis® form Traditional & Optimized (03/2018) or Medicare (05/2018)
Procrit® forms Medicaid (02/2018) or Medicare Part B vs. Part D determination (09/2017)
Prolastin®
 forms Traditional, Optimized, & Medicaid (03/2018) or Medicare (03/2018)
Prolia® forms Traditional, Optimized, & Medicaid (07/2017) or Medicare (01/2018)
Promacta® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Promethazine form Medicare only (01/2017)
Provenge® forms Traditional, Optimized, & Medicaid (11/2017) or Medicare (11/2016)
Pulmozyme® forms Traditional (11/2017) or Optimized (11/2017) or Medicaid (02/2018)

Q, R

Qtern® form Optimized (01/2018)
Radicava® forms Traditional & Optimized (09/2017) or Medicare (09/2017)
Ranexa® form Medicaid only (02/2018)
Ravicti®
 forms Traditional & Optimized (01/2018) or Medicare (01/2017)
Rayaldee® form Medicare only (03/2018)
Rebif® form Optimized (05/2018)
Relistor® injection forms Traditional & Optimized (01/2018) or Medicare (11/2017)
Relistor® tablets form Traditional & Optimized (01/2018)
Remicade® forms Traditional & Optimized (01/2018) or Medicaid (01/2018) or Medicare (01/2018)
Remodulin® 
form Traditional & Optimized (01/2018)
Renflexis™ forms Traditional, Optimized, & Medicaid (01/2018) or Medicare (03/2018)
Repatha® form Traditional & Optimized (03/2017)
Revlimid® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Rituxan® forms Traditional, Optimized, & Medicaid (09/2017) or Medicare (09/2017)
Rituxan Hycela™ form Traditional, Optimized, & Medicaid only (03/2018)
Rubraca® forms Traditional & Optimized (05/2018) or Medicare (03/2017)
Ruconest® forms Traditional & Optimized (01/2018) or Medicare (01/2017)
Rydapt® forms Traditional & Optimized (07/2017) or Medicare (07/2017)

S

Sabril® form Traditional & Optimized (11/2017)
Samsca®
 forms Traditional & Optimized (09/2017) or Medicare (09/2017)
Sancuso® form Medicare only (05/2018)
Serostim® forms Traditional & Optimized (05/2018) or Medicare (05/2018)
Signifor® forms Traditional & Optimized (07/2016) or Medicare (07/2017)
Signifor LAR® form Traditional & Optimized (05/2018)
Sildenafil 20 mg tablet forms Traditional & Optimized (02/2018) or Medicaid (02/2018) or Medicare (03/2018)
Siliq® forms Traditional & Optimized (03/2018) or Medicare (09/2017)
Simponi® and Simponi Aria® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Sivextro® forms Traditional & Optimized (03/2017) or Medicare (03/2017)
Smoking cessation products form Traditional, Optimized, & Medicaid (11/2017)
Soliqua form Optimized (05/2018)
Soliris® forms Traditional & Optimized, & Medicaid (03/2018) or Medicare (05/2018)
Somavert® form Traditional & Optimized (01/2018)
Sovaldi® forms Traditional (11/2017) or Optimized (11/2017) or Medicare (01/2018)
Spinrazaform Traditional & Optimized (05/2018)
Sporanox® Traditional & Optimized (05/2018)
Sprycel® forms Traditional & Optimized (01/2018) or Medicare (07/2017)
Stelara® forms Traditional & Optimized (05/2018) or Medicare (03/2018)
Stimate® form Medicaid only (04/2018)
Stivarga® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Strensiq® form Traditional & Optimized (01/2018)
Striant® forms Traditional & Optimized (01/2017) or Medicare (01/2017)
Suboxone® forms Optimized (09/2017) or Medicare (05/2018)
Subsys® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Sumatriptan spray and injection form Medicaid only (05/2018)
Supprelin LA® form Traditional & Optimized, & Medicaid (09/2017)
Surmontil® form Medicare only (01/2017)
Sutent® forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Sylatron® forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Sylvant® forms Traditional, Optimized, & Medicaid (09/2017) or Medicare (09/2017)
Synagis® forms Traditional & Optimized (02/2018) or Medicaid (02/2018)
Synjardy®/Synjardy® XR forms Optimized (01/2018) or Medicaid (02/2018)
Synribo® form Medicare only (01/2017)
Syprine® form Traditional & Optimized (03/2018)

T

Tafinlar® forms Traditional & Optimized (09/2017) or Medicare (09/2017)
Tagrisso® forms Traditional & Optimized (05/2018) or Medicare (05/2018)
Taltz® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Tanzeum® forms Optimized (11/2017) or Medicaid (02/2018)
Tarceva® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Targretin® forms Traditional & Optimized (05/2018) or Medicare (05/2018)
Tasigna® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Tecentriq® form Traditional, Optimized, & Medicaid only (01/2018)
Tecfidera® forms Optimized (05/2018) or Medicaid  (02/2018)
Technivie® forms Traditional (11/2017) or Optimized (11/2017)
Temozolomide form Traditional & Optimized (03/2018)
Testopel® form Traditional & Optimized (05/2018)
Testosterone, topical forms Traditional & Optimized (05/2018) or Medicare (03/2018)
Tetrabenazine form Traditional & Optimized (03/2018)
Thalomid® forms Traditional & Optimized (03/2017) or Medicare (07/2017)
Thiola® form Traditional & Optimized (03/2018)
TOBI® Podhaler form Traditional & Optimized (02/2018) or Medicaid (02/2018)
Tobramycin form Traditional & Optimized (02/2018) or Medicaid (02/2018)
Tofranil™ form Medicare only (11/2017)
Torisel® form Medicare only (11/2017)
Tracleer® forms Traditional & Optimized (11/2017) or Medicaid (02/2018)
Tradjenta® forms Optimized (03/2017) or Medicaid (02/2018)
Tramadol ER form Optimized (09/2017)
Tremfya™ form Traditional & Optimized (05/2018) or Medicare (11/2017)
Tretinoin capsules forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Trientine form Traditional & Optimized (04/2018)
Trulicity® form Optimized (11/2017)
Tykerb® forms Traditional & Optimized (03/2018) or Medicare (07/2017)
Tymlos® forms Traditional & Optimized (07/2017) or Medicaid (04/2018) or Medicare (07/2017)
Tysabri® forms Traditional & Optimized, & Medicaid (03/2018) or Medicare (03/2018)
Tyvaso® forms Traditional & Optimized (03/2018) or Medicare (01/2017)

U

Unituxin® form Traditional, Optimized, & Medicaid (07/2017)
Uptravi® forms Traditional, Optimized, & Medicaid (03/2018) or Medicare (05/2018)

V

Valchlor® forms Traditional & Optmized (01/2018) or Medicare (01/2017)
Valganciclovir form Medicaid only (05/2018)
Vascepa® forms Traditional & Optimized (01/2017) or Medicare (01/2017)
Vectibix® forms Traditional, Optimized, & Medicaid (09/2016) or Medicare (09/2016)
Velcade® form Traditional, Optimized, & Medicaid (05/2018)
Veletri® form Traditional, Optimized, & Medicaid (03/2018)
Vemlidy® form Medicaid only (02/2018)
Venclexta™ forms Traditional & Optimized (07/2017) or Medicare (01/2017)
Ventavis® forms Traditional & Optimized (03/2017) or Medicare (07/2017)
Verzenio® forms Traditional & Optimized (03/2018) or Medicare only (03/2018)
Vesanoid® forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Viberzi® form Traditional & Optimized (09/2017)
Victoza® forms Optimized (11/2017) or Medicaid (02/2018)
Viekira Pak® forms Traditional & Optimized (11/2017) or MyPriority (11/2017)
Vimizim® form Traditional & Optimized (05/2018)
Vivlodex® form Traditional & Optimized (05/2018)
Vosevi™ forms Traditional (11/2017) or Optimized (11/2017)
Votrient® forms Traditional & Optimized (07/2017) or Medicare (07/2017)
Vpriv® form Traditional, Optimized, & Medicaid (05/2018)
Vyxeos® form Traditional, Optimized, & Medicaid (03/2018)

W, X

Xalkori® forms Traditional & Optimized (05/2018) or Medicare (07/2017)
Xarelto® form Medicaid only (02/2018)
Xatmep™ form Medicare only (03/2018)
Xeljanz® or Xeljanz XR® forms Traditional & Optimized (02/2018) or Medicare (03/2018)
Xermelo™ form Traditional & Optimized (05/2018)
Xgeva® form Traditional, Optimized, & Medicaid (03/2018)
Xiaflex® form Traditional, Optimized, & Medicaid (01/2018)
Xifaxan® form Medicare only (01/2017)
Xigduo XR® form Optimized only (01/2018)
Xolair® forms Traditional, Optimized, & Medicaid (01/2018) or Medicare (05/2018)
Xtampza™ form Optimized (05/2018)
Xtandi® forms Traditional, Optimized, & Medicaid (05/2018) or Medicare (02/2018)
Xultophy® form Optimized (05/2018)
Xyrem® forms Traditional & Optimized (05/2018) or Medicare (03/2018)

Y

Yervoy® forms Traditional, Optimized, & Medicaid (01/2017) or Medicare (07/2017)
Yescarta™ form Traditional & Optimized (03/2018)
Yondelis® forms Traditional, Optimized, & Medicaid (01/2018) or Medicare (01/2017)

Z

Zaleplon form Medicare only (01/2018)
Zarxio® form Medicaid only (02/2018)
Zejula® forms Traditional & Optimized (07/2017) and Medicare (07/2017)
Zelboraf® forms Traditional & Optimized (03/2018) or Medicare (03/2018)
Zemaira® forms Traditional, Optimized, & Medicaid (03/2018) or Medicare (03/2018)
Zenatane™ form Traditional & Optimized (05/2018)
Zepatier™ forms Traditional (05/2018) or Optimized (05/2018) or Medicare (01/2018)
Zevalin® form Traditional, Optimized, & Medicaid (11/2017)
Zinbryta™ form Optimized (05/2018)
Zohydro ER® forms Traditional & Optimized (05/2018) in addition, have the patient complete a Pain management agreement, or Medicare (05/2018)
Zolinza® forms Traditional & Optimized, & Medicaid (03/2018) or Medicare (03/2018)
Zolpidem/Zolpidem ER form Medicare only (01/2018)
Zorbtive® form Traditional & Optimized (09/2017)
Zubsolv® forms Optimized (09/2017) or Medicare (11/2017)
Zydelig® forms Traditional & Optimized (09/2016) or Medicare (09/2017)
Zykadia® forms Traditional & Optimized (11/2017) or Medicare (11/2017)
Zytiga® forms Traditional, Optimized, & Medicaid (05/2018) or Medicare (06/2018)
Zyvox® forms Traditional & Optimized (02/2018) or Medicaid (02/2018) or Medicare (02/2018)