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.
- 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