PDL Drug Prior Authorization Forms

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Please refer to the following KMAP Provider manuals for PA process details:

• For Pharmacy claims refer to the Pharmacy manual
• For Professional claims refer to the General Special Requirements manual
   
  KMAP (Fee For Service) PA Call Center
  Phone:  800-285-4978
              785-274-5956
  Fax:      800-913-2299
  Hours: Mon. – Fri.
              7:30a.m. – 5:30p.m.
  

PA Forms for PDL Drugs (listed by class)

• 2nd Generation Sulfonylureas
• 5-HT Receptor Antagonists (Triptans)
• ACE Inhibitors
• ACE Inhibitors ⁄ Calcium Channel Blockers
• Adjunct Antiepileptics
• Alphaglucosidase Inhibitors
• Angiotensin II Receptor Antagonist (ARBs)
• Beta-Blockers
• Biguanides
• Biologics
• Bisphosphonates
• Calcium Channel Blockers (CCBs)
• Fibric Acid Derivatives
• Growth Hormone Therapy ADULT Request
• Growth Hormone Therapy CHILD INITIAL Request
• Growth Hormone Therapy CHILD RENEWAL Request
• H2 Antagonists
• HMG-CoA Reductase Inhibitors (Statins)
• Incretin Mimetics – See Clinical PA Forms section (Exenatide and Exenatide ER)
• Inhaled Beta 2 Agonists – Long Acting
• Inhaled Beta 2 Agonists – Short Acting
• Inhaled Corticosteroids
• Insulin Delivery Systems
• Intranasal Corticosteroids
• Meglitinides
• Muscle Relaxants
• Non-Benzodiazepine Sedative Hypnotics and Sleep Agents
• Non-Sedating Antihistamines
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
• Ophthalmic Prostaglandin Analogs
• Overactive Bladder Drugs
• Proton Pump Inhibitors (PPIs)
• Serotonin 5HT3 Antagonists
• Xanthine Oxidase Inhibitors

Clinical PA Forms

• Abatacept (Orencia®)
• Adalimumab (Humira®)
• Alefacept (Amevive®)
• Anakinra (Kineret®)  
• Aromatase Inhibitor Products
• Becaplermin (Regranex®) INITIAL Request  
• Becaplermin (Regranex®) RENEWAL  Request
• Botulinum Toxins
• Buprenorphine/Naloxone (Suboxone®) and Buprenorphine (Subutex®)
• Canakinumab (Ilaris)
• Carisoprodol (Soma®)
• Certolizumab (Cimzia®)
• DAW Request for Brand Name Medication
• Decubitus Products
• Enfuvirtide (Fuzeon®)  
• Etanercept (Enbrel®)
• Exenatide (Byetta®) INITIAL Request
• Exenatide (Byetta®) RENEWAL Request
• Exenatide Extended-Release (Bydureon®) INITIAL Request
• Exenatide Extended-Release (Bydureon®) RENEWAL Request
• Fentanyl Citrate (Actiq®, Fentora®, Lazanda®, Onsolis®, Abstral®, Subsys®)
• Golimumab (Simponi®)
• Growth Hormone Therapy ADULT Request
• Growth Hormone Therapy CHILD INITIAL Request 
• Growth Hormone Therapy CHILD RENEWAL Request  
• Inflixumab (Remicade®)
• Inhaled Beta 2 Agonists – Long Acting
• Linezolid (Zyvox®)
• Liraglutide (Victoza®)
• Long Acting Opioid Products
• Maraviroc (Selzentry®)
• Mecasermin (Increlex®)  
• Meperidine/Hydromorphone/Oxycodone SR®
• Methylnaltrexone (Relistor®)
• Nabilone (Cesamet®)
• Narcotic/Muscle Relaxant Products
• Natalizumab (Tysabri®)
• Omalizumab (Xolair®) INITIAL Request
• Omalizumab (Xolair®) RENEWAL Request
• Palivizumab (Synagis®) INITIAL Request
• Palivizumab (Synagis®) Status Request
• Pimecrolimus (Elidel®) ⁄ Tacrolimus (Protopic®) INITIAL Request
• Pimecrolimus (Elidel®) ⁄ Tacrolimus (Protopic®) RENEWAL Request
• Plerixafor Injection (Mozobil®)
• Pramlintide (Symlin®) INITIAL Request
• Pramlintide (Symlin®) RENEWAL Request
• Proton Pump Inhibitors (PPIs) – for quantity limitation override only
• Retinoid Products  
• Rifampin and Tuberculosis Products
• Rituximab (Rituxan®)
• Telithromycin (Ketek®)
• Teriparatide (Forteo®)  
• Tocilizumab (Actemra®)
• Ustekinumab (Stelara®)
• Weight Loss Products INITIAL Request  
• Weight Loss Products RENEWAL Request