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 3/11/20
• 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