Pharmacy Help Desk: 1-877-209-1264, Provider PA Help Desk: 1-877-207-1126
Listed below are all the PA forms you will need in order to request drugs that require prior authorization.
To submit a request:
- Select and print the proper form from the list below
- Fill out the form completely
- Fax the completed form to us at 1-866-964-3472
(Please note - If the PA form asks for supporting medical documentation, please fax this information along with the completed PA form.)
The forms are provided here in MS Word. If you cannot view a file, please download the appropriate free plug-in
from the links below.