Prior Authorization

Pharmacy Quick Links

Preferred Drug List P&T Committee Prior Authorization Drug Utilization Review Board Drug Utilization Review (DUR) Program Medication Therapy Management Services

Listed below are all the PA forms you will need in order to request drugs that require prior authorization.

To submit a request via fax:

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