Last verified: Feb 21, 2025

Jevtana prior authorization forms by payer

Medicare, Medicaid, and commercial pharmacy prior authorization forms. general forms | drug-specific forms by payer | forms by region & state.

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Arizona

Last verified: Feb 21, 2025Arizona - Uniform Prior Authorization Form

Arkansas Blue Cross Blue Shield

Last verified: Feb 18, 2025Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form

Blue Cross Blue Shield of Arizona, Inc.

Last verified: Feb 18, 2025Blue Cross Blue Shield of Arizona - General Prior Authorization Form

Blue Cross Blue Shield of Massachusetts

Last verified: Mar 15, 2025Blue Cross Blue Shield of Massachusetts - Medicare Part D Prior Authorization Form

Blue Cross Blue Shield of Michigan

Last verified: Feb 23, 2025Medicare Plus Blue and BCN Advantage of Michigan - Global PA Form

Blue Cross Blue Shield of Tennessee

Last verified: Feb 18, 2025Blue Cross Blue Shield of Tennessee - Specialty Pharmacy Prior Authorization Form

Blue Cross of Idaho Health Services, Inc.

Last verified: Feb 18, 2025Blue Cross of Idaho - Medicare Part B Pharmacy Prior Authorization Form Last verified: Feb 18, 2025Blue Cross of Idaho - General Prior Authorization Form

Capital District Physicians Health Plan, Inc.

Last verified: Mar 09, 2025CDPHP - General Prior Authorization Form

Cigna Corporation

Last verified: Feb 19, 2025Cigna - Jevtana Prior Authorization Form Last verified: Feb 19, 2025Cigna - General Injectables Prior Authorization Form Last verified: Feb 19, 2025Cigna - General Medication Prior Authorization Form

Colorado

Last verified: Feb 21, 2025Colorado - Uniform Prior Authorization Form

Curative Health Insurance

Last verified: Mar 09, 2025Curative Health Insurance - Prior Authorization Form

CVS Caremark

Last verified: Feb 19, 2025Caremark - Formulary Exception and Prior Authorization Form

CVS Health (Aetna)

Last verified: Mar 02, 2025Aetna - Medical Exception/Prior Authorization/Precertification Request for Prescription Medications Last verified: Mar 02, 2025Aetna - Medicare Prescription Drug Coverage Determination Last verified: Mar 02, 2025Aetna - Oregon Prior Authorization/Medical Exception/Precertification Form Last verified: Mar 02, 2025Aetna - Texas Prior Authorization Form Last verified: Mar 02, 2025Aetna - New York Contraceptive Exemption Request Form Last verified: Mar 02, 2025Aetna - New Hampshire Prior Authorization Form Last verified: Mar 02, 2025Aetna - Louisiania Prior Authorization Request Form Last verified: Mar 02, 2025Aetna - Iowa Prior Authorization/Medical Exception/Precertification Request Form Last verified: Mar 02, 2025Aetna - Illinois Prior Authorization Request Form Last verified: Mar 02, 2025Aetna - California Prior Authorization Form Last verified: Mar 02, 2025Aetna - Arizona Prior Authorization Form

Express Scripts (ESI)

Last verified: Mar 07, 2025Express Scripts - General Prior Authorization Form

Hawaii

Last verified: Feb 21, 2025Hawaii - Uniform Prior Authorization Form

Health Partners Plans

Last verified: Feb 18, 2025Health Partners - General Prior Authorization Form

Highmark, Inc.

Last verified: Feb 25, 2025Highmark BCBS Northeastern NY - Medicare Prescription Drug Medication Request Form Last verified: Feb 25, 2025Highmark BCBS Western NY - Specialty Drug Prior Authorization Form Last verified: Feb 25, 2025Highmark BCBS Western NY - Non-Formulary Drug Coverage Prior Authorization Form Last verified: Feb 25, 2025Highmark BCBS Western NY - Medicare Specialty Drug Request Form Last verified: Feb 25, 2025Highmark BCBS Western NY - Medicare Prescription Drug Medication Request Form Last verified: Feb 25, 2025Highmark BCBS Western NY - Chronic Inflammatory Diseases Prior Authorization Form Last verified: Feb 25, 2025Highmark BCBS Western NY - Outpatient Medical Injectable Specialty Drug Prior Authorization Form Last verified: Feb 24, 2025Highmark BCBS West Virginia - Request for Drug Coverage from Pharmaceutical Management Program Last verified: Feb 24, 2025Highmark BCBS West Virginia - Specialty Drug Prior Authorization Form Last verified: Feb 24, 2025Highmark BCBS Delaware - Specialty Drug Prior Authorization Form Last verified: Feb 24, 2025Highmark BCBS Delaware - Prescription Drug Prior Authorization Form Last verified: Feb 24, 2025Highmark BCBS West Virginia - Medical Injectable Specialty Drug Prior Authorization Form Last verified: Feb 24, 2025Highmark BCBS Delaware - Medical Injectable Specialty Drug Authorization Request Form Last verified: Feb 24, 2025Highmark BCBS Central PA - Medical Injectable Specialty Drug Chemotherapy Prior Authorization Form Last verified: Feb 24, 2025Highmark BCBS Central PA - Non-Formulary Drug Prior Authorization Form Last verified: Feb 24, 2025Highmark BCBS Central PA - Specialty Drug Prior Authorization Form Last verified: Feb 23, 2025Highmark BCBS Western PA - Medical Injectable Specialty Drug Prior Authorization Form Last verified: Feb 23, 2025Highmark BCBS Western PA - Specialty Drug Prior Authorization Form Last verified: Feb 23, 2025Highmark BCBS Western PA - Non-Formulary Drug Prior Authorization Form

Humana, Inc.

Last verified: Mar 15, 2025Humana - Medicare Prior Authorization Form Last verified: Mar 15, 2025Humana - General Prior Authorization Form

Illinois

Last verified: Feb 21, 2025Illinois - Uniform Prior Authorization Form

Independent Health Association, Inc.

Last verified: Mar 15, 2025Independence Health - Medicare Part D Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Independence Health - Value Formulary Prior Authorization Form Last verified: Mar 15, 2025Independence Health - Premium Formulary Prior Authorization Form Last verified: Mar 15, 2025Independence Health - Select Formulary Prior Authorization Form

Indiana

Last verified: Feb 21, 2025Indiana - Uniform Prior Authorization Form

Kaiser Foundation Health Plans, Inc.

Last verified: Mar 11, 2025Kaiser Permanente of Colorado - Medicare Medication Request form (MRF)Last verified: Mar 11, 2025Kaiser Permanente of Colorado HMO - Uniform Pharmacy Prior Authorization Request Form

Louisiana

Last verified: Feb 21, 2025Louisiana - Uniform Prior Authorization Form

Medica Health Plans

Last verified: Mar 15, 2025Medica - Pharmacy Prior Authorization Form

Medical Mutual of Ohio Corporation

Last verified: Feb 18, 2025Medical Mutual of Ohio - General Prior Authorization Form

Minnesota

Last verified: Feb 21, 2025Minnesota - Uniform Prior Authorization Form

Molina Health Care, Inc.

Last verified: Mar 15, 2025Molina - Wisconsin Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Washington Specialty Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Washington Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina- Utah Medical Benefit Drug Prior Authorization Form Last verified: Mar 15, 2025Molina - Utah Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - South Carolina Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Ohio Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Mississippi Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Michigan Medicare Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Michigan Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Kentucky Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Illinois Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Idaho Medical Benefit Drug Prior Authorization Form Last verified: Mar 15, 2025Molina - Idaho Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - Florida Pharmacy Prior Authorization Form Last verified: Mar 15, 2025Molina - California Medical Benefit Drug Prior Authorization Form

MVP Health Care, Inc.

Last verified: Feb 18, 2025MVP Health Care - NYS Medicaid Pharmacy Prior Authorization Form Last verified: Feb 18, 2025MVP Health Care - Pharmacy Prior Authorization Form

New Hampshire

Last verified: Feb 21, 2025New Hampshire - Uniform Prior Authorization Form

New Mexico

Last verified: Feb 21, 2025New Mexico - Uniform Prior Authorization Form

OptumRx

Last verified: Mar 12, 2025OptumRx - General Prior Authorization Form

Oregon

Last verified: Feb 21, 2025Oregon - Uniform Prior Authorization Form

PacificSource Health Plan

Last verified: Feb 18, 2025Pacific Source - Medicaid Community Solutions Prior Authorization Form Last verified: Feb 18, 2025Pacific Source - Pharmacy Prior Authorization Form

Premera, Inc.

Last verified: Feb 18, 2025Premera - Pharmacy Prior Authorization Form

Providence Health System

Last verified: Feb 18, 2025Providence Health Plan - Drug Prior Authorization Form

Texas

Last verified: Feb 21, 2025Texas - Uniform Prior Authorization Form

Washington

Last verified: Mar 04, 2025Washington - Uniform Prior Authorization Form

Wisconsin

Last verified: Mar 04, 2025Wisconsin - Uniform Prior Authorization Form