Statewide PDL Drugs/Drug Classes Fax Forms*
NOTE: Please use the Non-Preferred Medication Form for drugs included on the Statewide PDL that do not have a corresponding drug-specific or PDL class-specific form in the list below.
- Acne Agents, Oral Form
- Acne Agents, Topical Form
- Analgesics, Non-Opioid Barbiturate Combinations Form
- Analgesics, Opioids Long-Acting Form
- Analgesics, Opioids Short-Acting Form
- Androgenic Agents Form
- Antibiotics, GI and Related Agents Form
- Antidepressants, Other
- Antifibrotic Respiratory Agents
- Antihemophilia Agents Form
- Antihyperuricemics - Krystexxa Form
- Antipsychotics Form
- Antivirals, CMV Form
- Benzodiazepines Form
- Bile Salts - Cholbam and Ocaliva Form
- Blood Glucose Meters and Test Strips Form
- Bone Density Regulators Form
- Botulinum Toxins Form
- Colony Stimulating Factors Form
- Continuous Glucose Monitoring Products Form
- COPD Agents - Daliresp Form
- Cytokine and CAM Antagonists Form
- Dupixent Form
- Enzyme Replacements, Gaucher Disease Form
- Erythropoiesis Stimulating Agents Form
- Estrogens Form
- GI Motility, Chronic
- Growth Hormones Form
- Hepatitis C Agents Form
- Hereditary Angioedema Agents Form
- Hypoglycemics, Incretin Mimetics-Enhancers Form
- Immunomodulators, Atopic Dermatitis
- Immunosuppressives, Oral - Lupkynis Form
- Intra-Articular Hyaluronates Form
- Iron Chelating Agents Form
- Lipotropics, Other Form
- Macular Degeneration Agents Form
- Migraine Acute Treatment Agents Form
- Migraine Prevention Agents Form
- Monoclonal Antibodies - Anti-IL, Anti-IgE, Anti-TSLP Form
- Multiple Sclerosis Form
- Natalizumb Form
- NSAIDs - Ketorolac Form
- Obesity Treatment Agents Form
- Oncology Agents, Oral Form
- Opioid Use Disorder Treatments Form
- Pituitary Suppressive Agents, LHRH Form
- Potassium Removing Agents Form
- Proton Pump Inhibitors < 6 Years of Age Form
- Pulmonary Hypertension Agents, Oral and Inhaled Form
- Sickle Cell Anemia Agents Form
- Stimulants and Related Agents Form
- Stimulants and Related Agents - Provigil, Nuvigil, Sunosi, and Wakix Form
- Thalidomide and Derivatives Form
- Thrombopoietics Form
- Ulcerative Colitis Agents Form
- Urea Cycle Disorder Agents Form
- VMAT2 Inhibitors Form
Fee-for-Service Non-PDL Drugs/Drug Classes Fax Forms
- Abecma Form
- Adstiladrin Form
- Alpha-1 Proteinase Inhibitors Form (Aralast-NP, Glassia, Prolastin-C, Zemaira)
- Amvuttra Form
- Amyloid-Targeted Monoclonal Antibodies (MABs) Form (Kisunla, Leqembi)
- Benlysta Form
- Brand Medically Necessary Form
- Breyanzi Form
- Brineura Form
- Camzyos Form
- Carvykti Form
- Casgevy Form
- CFTR Modulators Form (Kalydeco, Orkambi, Symdeko, Trikafta)
- Complement Inhibitors (Empaveli, Enjaymo, Fabhalta, Piasky, Soliris, Tavneos, Ultomiris, Veopoz, Voydeya, Zilbrysq)
- Compounded Prescriptions Form
- Corlanor Form
- Corticotropin Form
- Cough and Cold Medications Form
- Crysvita Form
- Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides Form (Amondys-45, Exondys 51, Viltepso, Vyondys 53)
- Elevidys Form
- Elitek Form
- Evrysdi Form
- Filspari Form
- Filsuvez Form
- Hyftor Form
- Imcivree Form
- Immune Globulins Form
- Iqirvo Form
- Joenja Form
- Jynarque Form
- Kanuma Form
- Korlym Form
- Kuvan Form
- Kymriah Form
- Lyfgenia Form
- Mozobil Form
- Nuedexta Form
- Omisirge Form
- Onpattro Form
- Palforzia Form
- Palynziq Form
- Provenge Form
- Quantity Limits/Daily Dose Limits Form
- Radicava Form
- Rezdiffra Form
- Roctavian Form
- Rystiggo Form
- Skyclarys Form
- Skysona Form
- Spinraza Form
- Synagis Form
- Tecartus Form
- Tegsedi Form
- Tepezza Form
- Therapeutic Duplication Form
- Tzield Form
- Uplizna Form
- Vecamyl Form
- Veozah Form
- Vijoice Form
- Vuity Form
- Vyjuvek Form
- Vyndamax Form
- Vyndaqel Form
- Vyvgart Form
- Wainua Form
- Winrevair Form
- Xermelo Form
- Xofigo Form
- Xyrem and Xywav Form
- Yescarta Form
- Zolgensma Form
- Zynteglo Form