Self-Administered Drug Prior Authorization 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.

Pharmacy drug policies provide a guide to coverage. Pharmacy policies are not intended to dictate to providers how to practice medicine. Providers should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Note: Coverage is subject to the member's specific benefits. Group-specific benefits will supersede these policies when applicable. Always verify member eligibility and benefits.

Forms

Click on the appropriate link below to print the form to request prior authorization for these drugs: