Prior Authorization

Prior Authorization

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.

With the implementation of our new pharmacy point of sale system, the fax number for requesting pharmacy prior authorizations will change. Effective Friday, February 17, 2012 the old fax number will no longer accept faxes. Beginning Sunday, February 19, 2012 prior authorization requests can be faxed to the new PA fax line at 855-828-4992. Please note that requests sent to the old fax number after this switch will not be received or processed.

The forms are provided in Adobe format. If you cannot view a file, please download the free plug-in from the link below.


     A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |

     72HourSupply.pdf        
     Adagen.pdf        
     AdultAcne.pdf        
     AgeQuantityOverride.pdf        
     Aldurazyme.pdf        
     Aloxi.pdf        
     Amevive.pdf        
     Amitiza.pdf        
     Ampyra.pdf        
     Androgens.pdf        
     AntibioticsIVforNTM.pdf        
     AntiEmeticIVforNTM.pdf        
     Aralast.pdf        
     Aranesp.pdf        
     Arava.pdf        
     Arixtra.pdf        
     Avastin.pdf        
     BotulinumToxins.pdf        
     Brand_Name_Medication.pdf        
     Butrans.pdf        
     Byetta.pdf        
     Cerezyme.pdf        
     Chantix.pdf        
     Cimzia_Crohns.pdf        
     Cimzia_RA.pdf        
     Colcrys.pdf        
     Combunox.pdf        
     Cycloset.pdf        
     Cytogam.pdf        
     DepoProvera.pdf        
     DPP-4_Inhibitors.pdf        
     DURBAppealRequest.pdf        
     Embeda.pdf        
     Emend.pdf        
     Emsam.pdf        
     Enbrel.pdf        
     Enbrel_JIA.pdf        
     Enbrel_Plaque_Psoriasis.pdf        
     EpinephrineNTM.pdf        
     Erythropoetins.pdf        
     Fabrazyme.pdf        
     Forteo.pdf        
     Gabapentin_ER.pdf        
     Gilenya.pdf        
     Growth_Hormone.pdf        
     Growth_Hormone_AIDS.pdf        
     Heparin_NTM.pdf        
     Hepsera.pdf        
     Humira.pdf        
     Humira_Crohns.pdf        
     Humira_JIA.pdf        
     Humira_Plaque_Psoriasis.pdf        
     Hydroxyprogesterone_Caproate.pdf        
     Increlex.pdf        
     InnohepNTM.pdf        
     Insulin_Pens.pdf        
     Istodax.pdf        
     Ketorolac.pdf        
     Kineret.pdf        
     Krystexxa.pdf        
     Lactulose.pdf        
     Lamisil.pdf        
     LowMolecularWeightHeparinsforNTM.pdf        
     Luxiq_Foam.pdf        
     Metabolic_Supplements.pdf        
     MSBiologicsforNTM.pdf        
     NeupogenNeulastaLeukine.pdf        
     Nexavar.pdf        
     Non-Preferred_Drug_Auth.pdf        
     Non-Sedating_Antihistamines.pdf        
     Nucynta.pdf        
     Nucynta_ER.pdf        
     Nuvigil.pdf        
     Olux_Foam.pdf        
     Omontys.pdf        
     Orencia.pdf        
     Oxandrin.pdf        
     Panretin.pdf        
     Pegasys&PegIntron.pdf        
     Pradaxa.pdf        
     Prolastin.pdf        
     Proton_Pump_Inhibitors.pdf        
     Provigil.pdf        
     Qualaquin.pdf        
     Raptiva.pdf        
     Regranex.pdf        
     Relenza.pdf        
     Relistor.pdf        
     Remicade.pdf        
     Remicade_Crohns.pdf        
     Remicade_JIA.pdf        
     Remicade_Plaque_Psoriasis.pdf        
     Remicade_Ulcerative_Colitis.pdf        
     Restasis.pdf        
     Retin-A.pdf        
     Sabril.pdf        
     Salagen.pdf        
     Samsca.pdf        
     Selzentry.pdf        
     Simponi.pdf        
     Simvastatin.pdf        
     Soliris.pdf        
     Somavert.pdf        
     Stimulants.pdf        
     Suboxone.pdf        
     Sutent.pdf        
     Symlin.pdf        
     Synagis.pdf        
     Tamiflu.pdf        
     Trizivir.pdf        
     Tykerb.pdf        
     Tysabri.pdf        
     Uloric.pdf        
     Vectibix.pdf        
     Victoza.pdf        
     Vivitrol.pdf        
     Vpriv.pdf        
     XanaxXR.pdf        
     Xarelto.pdf        
     Xibrom.pdf        
     Xolair.pdf        
     Xolegel.pdf        
     Xyrem.pdf        
     Zavesca.pdf        
     Zemaira.pdf        
     Ziana.pdf        
     ZoviraxOintment.pdf