Complete and Return
From time to time, you may be asked to complete and return specific forms to Serve You Rx. To request additional forms (such as drug-specific forms), please call 800-759-3203.
- 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
- Provider Network Final Audit Appeal Form
These forms are in .pdf (Acrobat) format. You can download the latest version of the Acrobat Reader software on Adobe’s website for free.