PA - Prior Authorization Forms
(click column headers to sort)Listed below are all the PA forms you will need in order to request drugs that require prior authorization.
To submit a request:
- Select and print the proper form from the list below
- Fill out the form completely
- Fax the completed form to us at 1-888-879-6938
(Please note - If the PA form asks for supporting medical documentation, please fax this information along with the completed PA form.)
The forms are provided here in MS Word. If you cannot view a file, please download the appropriate free plug-in from the links below.
- MS Word Viewer (.doc or .rtf)
- MS Excel Viewer (.xls)
- Acrobat Viewer (.pdf)
| Name | Description | Date |
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#10110 | 11/6/2007 |
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#20910 | 11/6/2007 |
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#10120 | 1/17/2008 |
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#10210 | 2/27/2008 |
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#10220 | 11/6/2007 |
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#10230 | 1/2/2008 |
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#10310 | 11/6/2007 |
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#10410 | 10/5/2005 |
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#10420 | 11/6/2007 |
|
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#10400 | 11/22/2006 |
|
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#10520 | 11/6/2007 |
|
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#10610 | 2/21/2008 |
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#10600 | 11/6/2007 |
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#10620 | 10/5/2005 |
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#10710 | 1/17/2008 |
|
|
12/22/2004 | |
|
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#20420 | 11/6/2007 |
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#20430 | 4/17/2008 |
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#20440 | 11/6/2007 |
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#20510 | 10/25/2007 |
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#20520 | 10/5/2005 |
|
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#20530 | 11/6/2007 |
|
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#20610 | 10/12/2007 |
|
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#20600 | 1/17/2008 |
|
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#20740 | 11/6/2007 |
|
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#20710 | 11/6/2007 |
|
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#10510 | 11/6/2007 |
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#30110 | 11/6/2007 |
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#30115 | 11/6/2007 |
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10/5/2005 | |
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#301501 | 11/6/2007 |
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#30120 | 11/15/2007 |
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#30130 | 2/27/2008 |
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#30140 | 10/5/2005 |
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#3400 | 1/2/2007 |
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#30820 | 1/2/2008 |