Pharmacy Forms
Prior Authorization Forms
- CoverMyMeds Electronic Prior Authorization Website
- IHCP Prior Authorization Form (PDF)
- Medication Prior Authorization Form (PDF)
- Pharmacy Prior Authorization Form (PDF)
Medical Pharmacy Prior Authorization Forms
- Antiviral Monoclonal Antibodies PA Form (PDF)
- 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)
- Narcolepsy Agents (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)
- Soma and Combinations PA Form (PDF)
- Testosterones PA Form (PDF)
- Uterine Disorder Agents PA Form (PDF)
- Vaginal Infection Antimicrobials PA Form (PDF)