Pharmacy Help Desk: 1-877-209-1264, Provider PA Help Desk: 1-877-207-1126

PA — Prior Authorization Forms

Listed below are all the PA forms you will need in order to request drugs that require prior authorization.

To submit a request:

  1. Select and print the proper form from the list below
  2. Fill out the form completely
  3. 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.

Additional PA News & Info

Prior Authorization Process

File Description Date
Website PA Process 167.99 KB 2010/08/06