You are here: Home » For Providers » Downloadable Forms

Downloadable Forms

Prior Authorization Forms for Non-Formulary Medications

To download a prior authorization form for a non-formulary medication, please click on the appropriate link below: (Note: Form must be approved before medication can be dispensed)

To download a medical necessity form for a non-formulary medication, please click on the appropriate link below: (Note: This form is not needed to obtain the medication at the non-formulary cost share of $25. It is to be used only if medically necessary to obtain the medication at the formulary cost share of $9 Mail Order 90 day supply or $12 Local Retail Network 30 day supply.)

 

Questions? Problems?

Let us know how we can help you.

Contact Us