Prior Authorization

Listed below are all the PA forms you will need in order to request drugs that require prior authorization.

To submit a request via fax:

• Select and print the proper form from the list below
• Gather all of the requested documentation, including a letter of medical necessity if requested.
• Fax the completed form to the Prior Authorization Team at (855) 828-4992.

The documents are provided in Adobe format. If you cannot view a file, please download the free plug-in from the link below.