Fee For Service Prior Authorization Forms

Makena (hydroxyprogesterone caproate injection)

Use either form. Refer to each form for requirements and submission instructions.

Form Name Form Number
Makena Authorization Request HHS 1345

Makena Standard PA Addendum

HHS 1346

Synagis (palivizumab)

Refer to the form for Synagis prior authorization requirements and submission instructions.

Xenical (orlistat)

Use either form. Refer to each form for requirements and submission instructions.

Form Name Form Number
Medicaid Xenical Clinic Prior Authorization HHS 1331

Medicaid Xenical Clinic Prior Authorization Addendum

HHS 1333
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