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Self-Administered Drug Prior Authorization Forms
Drug policies are based on:
- information in FDA-approved package inserts (and black box warnings, alerts or other information disseminated by the FDA, as applicable);
- research of current medical and pharmacy literature; and/or,
- review of common medical practices in the treatment and diagnosis of disease.
Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies, when applicable. Always verify member eligibilty and benefits.
Click on the appropriate link below to print the form to request prior authorization for these drugs:
|Buprenorphine and Buprenorphine/Naloxone Prior Authorization Form|
|Compound Coverage Authorization Request Form|
|General Prescription Drug Authorization Request Form|
|HSA Request Form|
|Opioids Request Form|
|PCSK9 Inhibitors Request Form|