Pharmacy Forms

Prior Authorization Forms

• CoverMyMeds Electronic Prior Authorization Information (PDF)
• Pharmacy Prior Authorization Form (PDF)
• Medical Pharmacy Prior Authorization Form (PDF)

Medical Pharmacy Prior Authorization Forms

• Bone Formation Stimulating Agents PA Form (PDF)
• Cardiac Agents PA Form (PDF)
• Dificid PA Form (PDF)
• Gralise, Horizant, and Lyrica CR PA Form (PDF)
• Growth Hormone PA Adult Form (PDF)
• Growth Hormone PA Child Form (PDF)
• Opioid PA Form - Request to Exceed MME Limit (PDF)
• Opioid with Concurrent Buprenorphine Products PA Form (PDF)
• PCSK9 Inhibitors and Select Lipotropics PA Form (PDF)
• Pulmonary Antihypertensives PA Form (PDF)
• Sickle Cell Agents PA Form (PDF)
• Soma and Combinations PA Form (PDF)
• Synagis PA From (PDF)
• Testosterones PA Form (PDF)
• Uterine Disorder Agents PA Form (PDF)
• Vaginal Infection Antimicrobials PA Form (PDF)