The federal government will end the COVID-19 emergency declarations on May 11, 2023. This means starting May 12, 2023, standard health plan provisions will apply with cost shares as applicable for COVID-19 testing, related services and vaccine administration. Read more
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