Pharmacy Prior Authorization Forms

Use this online form for pharmacy-related prior authorization requests:

• Online prior authorization request form

Other prior authorization forms:

• Opioid-containing products request form (PDF)
• Specialty prior authorization forms
• Hepatitis C prior authorization criteria (PDF)

Use this pharmacy reference guide for information regarding pharmacy provider services:

• Pharmacy reference guide (PDF)

Find a snapshot of helpful information regarding prior authorizations:  

• Prior authorization quick fact sheet (PDF)
• Prior authorization criteria (PDF)