New Jersey Community Plan Pharmacy Prior Authorization Forms

"Brand Adderall, generic amphetamine/dextroamphetamine, Brand Adderall XR, generic amphetamine/dextroamphetamine ER, Brand Intuniv, generic guanfacine ER, Brand Metadate ER, generic methylphenidate ER tab, generic methylphenidate ER (CD), Brand Concerta, generic methylphenidate ER OSM, Brand Ritalin, generic methylphenidate, generic methylphenidate ER (LA), Brand Ritalin LA, Brand Strattera, generic atomoxetine, Brand Vyvanse, Adhansia XR, Brand Adzenys XR-ODT, Brand Adzenys ER, generic amphetamine ER susp, Brand Aptensio XR, generic methylphenidate ER cap, Brand Cotempla XR-ODT, Brand Daytrana, Brand Desoxyn, generic methamphetamine, Brand Dexedrine, generic dextroamphetamine ER, Brand Dyanavel XR, Brand Evekeo, Evekeo ODT, generic amphetamine, Brand Focalin, generic dexmethylphenidate, Brand Focalin XR, generic dexmethylphenidate ER, Jornay PM, Brand Kapvay, generic clonidine ER, Brand Methylin, generic methylphenidate soln, Brand Mydayis, Brand Procentra, generic dextroamphetamine soln, Brand Quillichew ER, Brand Quillivant XR, Brand Zenzedi, generic dextroamphetamine, generic Relexxii, generic methylphenidate ER (OSM), Qelbree, Azstarys, generic methylphenidate patch ",

"Abilify Maintena, Abilify MyCite, Abilify, aripiprazole ODT, aripiprazole, Aristada, asenapine, Caplyta, chlorpromazine, clozapine, clozapine ODT, Clozaril, Fanapt, Fazaclo, fluphenazine, Geodon, Haldol, haloperidol decanoate, haloperidol, Invega, Invega Sustenna, Invega Trinza, Invega Hafyera, Latuda, loxapine, Lybalvi, molindone, olanzapine, olanzapine ODT, paliperidone, perphenazine, Perseris, pimozide, quetiapine, quetiapine ER, Rexulti, Risperdal Consta, Risperdal, risperidone ODT, risperidone, Saphris, Secuado, Seroquel, Seroquel XR, thioridazine, thiothixene, trifluoperazine, Versacloz, Vraylar, ziprasidone, Zyprexa, Zyprexa Zydis",

Dupixent,

Adlyxin, Bydureon, Byetta, Ozempic, Rybelsus, Trulicity, Victoza,

Epclusa; sofosbuvir/velpatasvir; Harvoni; ledipasvir/sofosbuvir; Mavyret; Sovaldi; Vosevi; Zepatier,

Synagis,

Morphine ER, Duragesic, Fentanyl transdermal, Zohydro ER, Hydrocodone ER, Oxymorphone ER, Hydromorphone ER, Hysingla ER, MS Contin, Nucynta ER, Oxycontin, Oxycodone CR, Xtampza ER, Methadose, Methadone, Conzip, Tramadol ER Butorphanol, Carisoprodol-aspirin-codeine, Codeine, Acetaminophen-codeine, Butalbital-acetaminophen-caffeine-codeine, Fioricet/codeine, Ascomp/codeine, Butalbital-aspirin-caffeine-codeine, Morphine, Hydrocodone-acetaminophen, Lortab, Xodol, Hydrocodone-ibuprofen, Dilaudid, Hydromorphone, Oxycodone, Roxicodone, Oxaydo, Oxycodone-acetaminophen, Percocet, Prolate, Nalocet, Endocet, Oxycodone-aspirin, Oxymorphone, Pentazocine-naloxone, Ultram, Synapryn, Tramadol, Qdolo, Ultracet, Tramadol-acetaminophen, Nucynta, Meperidine, Levorphanol, Acetaminophen-caffeine-dihydrocodeine, Trezix, Belladonna alkaloids-opium, opium, Apadaz, Benzhydrocodone-acetaminophen ,

Steglatro, Segluromet, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, Synjardy XR, Farxiga, Xigduo XR,

Suboxone Film, buprenorphine/naloxone film, buprenorphine/naloxone sublingual tablet, buprenorphine sublingual tablet, Zubsolv, Bunavail,