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.
- Amevive/Stelara updated 03/22/17
- Ampyra updated 01/23/18
- Androgen updated 03/24/17
- Bowel Prep Cost Share Reduction updated 10/07/16
- Contraceptive Out-of-Pocket Reduction updated 07/31/16
- Diabetic Test Strips updated 11/01/16
- Dispense as Written – Prescriber Indicated Penalty Waiver Form updated 11/04/19
- Entresto updated 12/09/16
- General Medication updated 01/29/14
- GI Protective NSAIDS updated 02/15/16
- Growth Hormone updated 03/01/16
- Hepatitis C Treatment updated 01/23/15
- HMG Co-A Reductase Inhibitor (Statin) updated 04/17/17
- Insulin updated 12/15/15
- Intravenous Immunoglobulin updated 11/28/16
- Migraine Quantity Maximum updated 03/01/16
- Multiple Sclerosis – Interferons updated 02/23/15
- Oral Acne Antibiotics updated 01/29/14
- Oral Fentanyl Quantity Maximum updated 01/29/15
- Oral Oncology Preauthorization Request Form updated 07/01/19
- Oxycodone ER Quantity Maximum updated 07/13/12
- Prolia updated 09/15/12
- Proton Pump Inhibitors updated 11/30/15
- Retinoids (Topical Acne Agents) updated 03/01/16
- Risk Reduction for Primary Breast Cancer in Women updated 09/09/14
- Synagis updated 01/23/18
- Tumor Necrosis Factor updated 06/30/15
- Xolair updated 03/13/17