Prior Authorization (PA)
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
- Gather all of the requested documentation, including a letter of medical necessity if requested.
- Fax the completed form to the Prior Authorization Team at (855) 828-4992.
The forms are provided in Adobe format. If you cannot view a file, please download the free plug-in from the link below.
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