Provider Forms
Complete and Return
This page lists forms you may be asked to complete and send back to us. To request additional forms (such as drug-specific forms), please call 800-759-3203.
If you need to submit a PA, you can complete the form and send it back to us or submit it online through our SureScripts electronic prior authorization (ePA) portal.
Provider Forms:
- BIN 610548 D.0 Payer Sheet
- Standard Prior Authorization Form
- Standard Prior Authorization Form (Louisiana Residents)
- Step Therapy Exception Form
- Quantity Limit Override Request Form
- Opioid – Long Acting Prior Authorization Form
- Opioid – Short Acting (Quantity Limits) Prior Authorization Form
- Compound Prior Authorization Form
- Women's Contraceptives ACA Exception Form
Note: All forms are in .pdf (Acrobat) format. You can download the latest version of the Acrobat Reader software on Adobe's website for free.