Prior Authorization (PA)
Listed below are all the PA forms you will need in order to request drugs that require prior authorization.
To submit a request:
With the implementation of our new pharmacy point of sale system, the fax number for requesting pharmacy prior authorizations will change. Effective Friday, February 17, 2012 the old fax number will no longer accept faxes. Beginning Sunday, February 19, 2012 prior authorization requests can be faxed to the new PA fax line at 855-828-4992. Please note that requests sent to the old fax number after this switch will not be received or processed.
- Select and print the proper form from the list below
- Gather all of the requested documentation, including a letter of medical necessity if requested.
- Fax the completed form to the Prior Authorization Team at (855) 828-4992.
The forms are provided in Adobe format. If you cannot view a file, please download the free plug-in from the link below.
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |