All of the forms are in .pdf format. You must have Adobe Acrobat Reader to view the forms. If you do not have Adobe Acrobat Reader, we recommend downloading and installing the latest version. For requests for agents not listed below, please use the General Prior Authorization Form at the top of the list below. If you need further assistance, please contact us at 1-866-773-0695.

• General Prior Authorization Form
• Benzodiazepine + Opioid Concurrent Use PA Form
• Concurrent Antipsychotics PA Form
• Continuous Glucose Monitoring PA Form
• Dupixent PA Form
• Emflaza PA Form
• Empaveli PA Form
• Evrysdi PA Form
• Growth Hormone PA Form
• Hepatitis C Treatments PA Form
• Hospice Drugs Not Related to Terminal Illness PA Form
• Medical Services Authorization Form
• MedWatch Form (Form FDA 3500)
• Mifeprex PA Form
• Migraine Prophylaxis/Treatment PA Form
• Nuedexta PA Form
• Opioid Analgesic - PA Form
• Opioid Dependence PA Form
• Palforzia PA Form
• Phenylketonuria Agents PA Form
• Sedative Hypnotic PA Form
• Synagis PA Form
• Tardive Dyskinesia PA Form
• Tubeless Insulin Pump PA Form