Prior Authorization Forms

 

Forms are revised periodically. Please refer to this page ot obtain the latest form update.

Click on the drug name to print the appropriate form. The form should be complete, signed and faxed by the physician to the number shown at the bottom of the form. Incomplete forms will be returned to the physician, which will delay the coverage determination.

Some drugs listed here are not included in the formulary for certain salaried, management, non-bargained hourly and bargained hourly employees/retirees. Refer to the formulary to identify drugs that are covered under your prescription drug benefit or contact Prime Therapeutics at 1-877-228-7909.

*Refers to a drug that's not covered under all plans.