Rhode Island 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 oral solution, aripiprazole, Aristada, Caplyta, clozapine, Clozaril, Fanapt, Geodon, Invega Sustenna, Invega, Invega Trinza, Latuda, olanzapine ODT, olanzapine, paliperidone ER, Perseris, quetiapine ER, quetiapine, Rexulti, Risperdal Consta, Risperdal oral solution, Risperdal, risperidone ODT, risperidone oral solution, risperidone, Saphris, Secuado, Seroquel XR, Seroquel, Versacloz, Vraylar, ziprasidone, Zyprexa Zydis, Zyprexa,

Hydromet, hydrocodone-homatropine, Z-Tuss AC, Tuzistra XR, Tussicaps, hydrocodone-chlorpheniramine, M-END PE, Poly-Tussin AC, Capcof, Pro-Red AC, Histex-AC, Maxi-Tuss, promethazine w/codeine, Promethazine VC/codeine, promethazine-phenylephrine-codeine, Rydex, Mar-Cof BP, Mar-Cof GG, Ninjacof-XG, Coditussin AC, Coditussin DAC, guaifenesin-codeine, Lortuss EX, pseudoephedrine w/codeine-guaifenesin, Tuxarin ER, Guiatuss AC, Lortuss, Tusnel C, Virtussin,

Cequa, Restasis, Restasis Multidose, Xiidra,

Dupixent,

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

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

Synagis,

Morphine ER, Xtampza, tramadol ER, Hydromorphone ER, MS Contin, fentanyl transdermal, Zohydro ER, hydrocodone ER, Oxymorphone ER, Methadose, Methadone, Hysingla ER, Oxycontin, oxycodone CR, Nucynta ER, Duragesic, Conzip Butorphanol, carisoprodol-aspirin-codeine, codeine, acetaminophen-codeine, butalbital-acetaminophen-caffeine-codeine, Fioricet-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, Ultracet, tramadol-acetaminophen, Qdolo, 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 sublingual film, buprenorphine sublingual tablet, Zubsolv, Bunavail, buprenorphine/naloxone,