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Pharmacy/Medication Prior Authorization

‘I am a pharmacist’ - Partners Tailored Plan
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For pharmacy prior authorization criteria for specific agents, please see documents posted at

Outpatient Pharmacy Medications


Partners Prior Authorization Request Forms

If a prior authorization is needed for a specific drug, use one of the following forms: (under development)

Physician Administered Drug Program (PDP) (under development)


The state Medicaid policy for the Physician Administered Drug Plan may be found at this link.

  • Physician Administered Drug Program (PDP) – Covers primarily injectable drugs or biologics purchased and given by a medical professional in an office or outpatient setting.
  • PDP catalog – This is a list of covered drugs and biologics with approved indications and restrictions. Click here to view the PDP catalog.
  • Off-label use – PDP requests can be submitted for off-label use. These requests should include the intended use of the drug.

Submit requests for PDP off-label uses via the Provider Portal.

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