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.

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

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

  Buprenorphine and Buprenorphine/Naloxone Prior Authorization Form
  Compound Coverage Authorization Request Form
  General Prescription Drug Authorization Request Form
  HSA Request Form
  Opioids Request Form
  PCSK9 Inhibitors Request Form

 

 

 

Policy # Policy Title Print View
PH-91019 Otezla (apremilast) Prior Authorization with Quantity Limit Program Summary