Self-Administered Drug 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.

 

Forms:

Buprenorphine and Buprenorphine/Naloxone Prior Authorization Form

Compound Coverage Authorization Request Form

General Prescription Drug Authorization Request Form

Opioids Request Form