Pharmacy Forms

Pharmacy Prior Authorization

Some medications listed on the MHS PDL may require a prior authorization. The prior authorization request should be submitted by the doctor or pharmacist on the Medication Prior Authorization Form. Directions on how to submit are included on this form.

MHS will cover medication if it is determined that:

• There is a medical reason the member needs the specific medication.
• Depending on the medication, other medications on the PDL have not worked.

Pharmacy Medication Prior Authorization Forms:

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

Request a Drug to Be Added to the PDL
Use this PDL Change Request form (PDF) to request that a drug be added to our preferred drug list.

Home Infusion Medications
For home infusion medications and related supplies, use the universal IHCP prior authorization form (PDF).

For more information on home infusion, see home infusion provider notice.

Specialty Forms:

• Specialty Pharmacy Prior Authorization Form (PDF)
• Drug/Disease Specific Specialty Prior Authorization Forms