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New Hampshire AIDS Drug Assistance Pharmacy Program

New Hampshire Tuberculosis Pharmacy Program

MMA New Hampshire AIDS Drug Assistance Program MMA NH ADAP

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Drug List for Faxed Forms

Adenosine Triphosphate-Citrate Lyase Inhibitor Prior Authorization Drug Approval Form
Allergen Extract Medications Prior Authorization Drug Approval Form
Antifungal Medication for Onychomycosis Prior Authorization Drug Approval Form
Asthma/Allergy Immunomodulator Prior Authorization Drug Approval Form
Bowel Disorder Medications Prior Authorization Drug Approval Form
Benign Prostatic Hyperplasia (BPH) Medications Prior Authorization/Non-Preferred Drug Approval Form
Brand Name Multiple Source Prescription Medications Prior Authorization Request Form
Buprenorphine/naloxone and buprenorphine (oral) Prior Authorization Drug Approval Form
Calcitonin Gene-Related Peptide (CGRP) Inhibitors for Migraine and Cluster Headache Prior Authorization Drug Approval Form
Carisoprodol and Combination Medications Prior Authorization Drug Approval Form
CNS Stimulant & ADHD/ADD Medication Prior Authorization Drug Approval Form
Codeine for Pediatric Use Prior Authorization Drug Approval Form
Convenience Kits Prior Authorization Drug Approval Form
Duloxetine Prior Authorization Drug Approval Form
Dupixent® Prior Authorization Drug Approval Form
Fibromyalgia Medications Prior Authorization Drug Approval Form
Hematopoietic Agent Prior Authorization Drug Approval Form
Hepatitis C Medications Prior Authorization Drug Approval Form
Hetlioz® Prior Authorization Drug Approval Form
Horizant® Prior Authorization Drug Approval Form
Inhaled Insulin Medications Prior Authorization Drug Approval Form
Juxtapid® Prior Authorization Drug Approval Form
Long Acting Opioid Analgesic Prior Authorization Drug Approval Form
Methadone Prior Authorization Drug Approval Form
Morphine Milligram Equivalent (MME) Prior Authorization Drug Approval Form
Movement Disorders Prior Authorization Drug Approval Form
New Drug Prior Authorization Drug Approval Form
Non-Preferred Prior Authorization Drug Approval Form
Oral Isotretinoin Medications Prior Authorization Drug Approval Form
Pregabalin Prior Authorization Drug Approval Form
Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Prior Authorization Drug Approval Form
Psychoactive Medications for Children (5 years of age or younger) Prior Authorization Drug Approval Form
Psychotropic Medications Duplicate Therapy (6 years of age or older) Prior Authorization Drug Approval Form
Pulmonary Arterial Hypertension – Phosphodiesterase Type-5 (PDE-5) Inhibitor Only Prior Authorization Drug Approval Form
Rho Kinase Inhibitor Medication Prior Authorization Drug Approval Form
Second-Line Antifungal Prior Authorization Drug Approval Form
Short-Acting Fentanyl Analgesic Medication Prior Authorization Drug Approval Form
Skin Disorders Prior Authorization Drug Approval Form
Spravato® Prior Authorization Drug Approval Form
Stromectol® Prior Authorization Drug Approval Form
Symlin® (pramlinitide acetate) Prior Authorization Drug Approval Form
Systemic Immunomodulators Medication Prior Authorization Drug Approval Form
Verquvo® Prior Authorization Drug Approval Form
Vuity® Prior Authorization Drug Approval Form
Weight Management Medications Prior Authorization Drug Approval Form

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