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) 

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

Form Name Form Number
Traditional Medicaid Synagis Prior Authorization Request HHS 1033
Traditional Medicaid Synagis Prior Authorization Request Addendum HHS 1321

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