Prior Authorization
PA Form Lookup
PA Forms
All of the forms are in .pdf format. You must have Adobe Acrobat Reader to view the forms. If you do not have Adobe Acrobat Reader, we recommend downloading and installing the latest version. For requests for agents not listed below, please use the General Prior Authorization Form at the top of the list below. See the Preferred Drug List (PDL) for information regarding preferred drug status and PA clinical criteria for coverage. If you need further assistance, please contact us at 1-866-773-0695.
- General Prior Authorization Form
- Provider Administered Drug (Medical Billing) PA Form
- MedWatch Form (Form FDA 3500)
- Asthma and COPD PA Form
- Benzodiazepine + Opioid Concurrent Use PA Form
- Concurrent Antipsychotics PA Form
- Continuous Glucose Monitoring PA Form
- Duchenne Muscular Dystrophy PA Form
- Dupixent PA Form
- Evrysdi PA Form
- Food Allergy PA Form
- GLP-1 and GIP/GLP-1 Agonist PA Form
- Growth Hormone PA Form
- Hepatitis C Treatments PA Form
- Hospice Drugs Not Related to Terminal Illness PA Form
- Mifepristone PA Form
- Migraine Prophylaxis/Treatment and Cluster Headache PA Form
- Myasthenia Gravis PA Form
- Nuedexta PA Form
- Opioid Analgesic - PA Form
- Paroxysmal Nocturnal Hemoglobinuria (PNH) PA Form
- Phenylketonuria Agents PA Form
- Precocious Puberty PA Form
- Primary Hyperoxaluria Type 1 (PH1) PA Form
- RSV Prophylaxis PA Form
- Sedative Hypnotic PA Form
- Tardive Dyskinesia PA Form
- Tubeless Insulin Pump PA Form
- Voquezna PA Form