Pharmacy Preauthorization Forms

Submit a pharmacy preauthorization by medication.

Submit a Pharmacy Pre-Authorization Online »

The below forms are available for providers that are unable to submit a preauthorization online through NaviNet.

• Acute CGRP Migraine updated 06/02/22
• Androgens updated 10/12/21
• Attention Deficit (Hyperactivity) Disorder (ADHD/ADD) updated 10/12/21
• Autoimmune Biologic Therapy updated 10/12/21
• Bowel Prep Cost Share Reduction updated 10/12/21
• Calcitonin Gene-related Peptide (CGRP) Inhibitor Migraine Prophylaxix updated 10/12/21
• Constipation Product updated 10/12/21
• Contraceptive Out-of-Pocket Reduction updated 10/12/21
• Dispense as Written – Prescriber Indicated Penalty Waiver Form updated 10/12/21
• General Medication updated 10/12/21
• Glucose Like Peptide-1 Agonists (GLP-1 Agonists) updated 10/12/21
• GI Protective NSAIDs updated 10/12/21
• Growth Hormone updated 10/12/21
• HCV updated 10/12/21
• HIV infection: Pre-exposure Prophylaxis (prep) medications updated 10/12/21
• HMG Co-A Reductase Inhibitor (Statin) updated 10/12/21
• HMG Co-A Reductase Inhibitor (Statin) Cost Share Reduction updated 7/19/23
• Insulin updated 12/23/21
• IVIG updated 10/12/21
• Migraine Quantity Maximum updated 12/23/21
• Multiple Sclerosis updated 10/12/21
• Oral Acne Antibiotics updated 10/12/21
• Oral Fentanyl Quantity Maximum updated 10/12/21
• Oral Oncology Preauthorization Request Form updated 10/12/21
• LA Oxycodone  updated 10/12/21
• Osteoporosis Treatments updated 10/12/21
• Proton Pump Inhibitors updated 10/12/21
• Retinoids (Topical Acne Agents) updated 10/12/21
• Risk Reduction for Primary Breast Cancer in Women updated 10/12/21
• Synagis updated 10/12/21
• Test Strips updated 10/12/21
• Xolair updated 10/12/21