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Opdualag prior authorization forms by payer
Medicare, Medicaid, and commercial pharmacy prior authorization forms. general forms | drug-specific forms by payer | forms by region & state.Arkansas Blue Cross Blue Shield
Blue Cross Blue Shield of Arizona, Inc.
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of Tennessee
Blue Cross of Idaho Health Services, Inc.
Cigna Corporation
CVS Caremark
CVS Health (Aetna)
Last verified: Apr 18, 2024Aetna - Opdualag Prior Authorization Form Last verified: Apr 18, 2024Aetna - Margenza Prior Authorization Form Last verified: Apr 18, 2024Aetna - Brineura Prior Authorization Form Last verified: Apr 18, 2024Aetna - Avastin Prior Authorization Form Last verified: Apr 17, 2024Aetna - Medicare Part B Gilenya Prior Authorization Form Last verified: Apr 16, 2024Aetna - Medicare Part B Brineura Prior Authorization Form Last verified: Apr 16, 2024Aetna - Medicare Part D Prior Authorization Form Last verified: Apr 16, 2024Aetna - Medical Advantage Prior Authorization Form Last verified: Apr 16, 2024Aetna - General Prior Authorization Form
Express Scripts (ESI)
Health Partners Plans
Highmark, Inc.
Last verified: May 01, 2024Highmark BCBS Northeastern NY - Medicare Prescription Drug Medication Request Form Last verified: May 01, 2024Highmark BCBS Northeastern NY - Short Acting Opioid Prior Authorization FormLast verified: May 01, 2024Highmark BCBS Western NY - Specialty Drug Prior Authorization Form Last verified: May 01, 2024Highmark BCBS Western NY - Non-Formulary Drug Coverage Prior Authorization Form Last verified: May 01, 2024Highmark BCBS Western NY - Medicare Specialty Drug Request FormLast verified: May 01, 2024Highmark BCBS Western NY - Medicare Prescription Drug Medication Request Form Last verified: May 01, 2024Highmark BCBS Western NY - Chronic Inflammatory Diseases Prior Authorization Form Last verified: May 01, 2024Highmark BCBS Western NY - Outpatient Medical Injectable Specialty Drug Prior Authorization Form Last verified: Apr 30, 2024Highmark BCBS West Virginia - Request for Drug Coverage from Pharmaceutical Management ProgramLast verified: Apr 30, 2024Highmark BCBS West Virginia - Specialty Drug Prior Authorization Form Last verified: Apr 30, 2024Highmark BCBS Delaware - Specialty Drug Prior Authorization Form Last verified: Apr 30, 2024Highmark BCBS Delaware - Prescription Drug Prior Authorization Form Last verified: Apr 30, 2024Highmark BCBS West Virginia - Medical Injectable Specialty Drug Prior Authorization Form Last verified: Apr 30, 2024Highmark BCBS Delaware - Medical Injectable Specialty Drug Authorization Request FormLast verified: Apr 30, 2024Highmark BCBS Central PA - Medical Injectable Specialty Drug Chemotherapy Prior Authorization Form Last verified: Apr 30, 2024Highmark BCBS Central PA - Non-Formulary Drug Prior Authorization Form Last verified: Apr 30, 2024Highmark BCBS Central PA - Specialty Drug Prior Authorization Form Last verified: Apr 29, 2024Highmark BCBS Western PA - Medical Injectable Specialty Drug Prior Authorization Form Last verified: Apr 29, 2024Highmark BCBS Western PA - Specialty Drug Prior Authorization Form Last verified: Apr 29, 2024Highmark BCBS Western PA - Non-Formulary Drug Prior Authorization Form
Humana, Inc.
Independent Health Association, Inc.
Last verified: Apr 19, 2024Independence Health - Medicare Part D Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Independence Health - Value Formulary Prior Authorization Form Last verified: Apr 19, 2024Independence Health - Premium Formulary Prior Authorization Form Last verified: Apr 19, 2024Independence Health - Select Formulary Prior Authorization Form
Kaiser Foundation Health Plans, Inc.
Louisiana
Medica Health Plans
Medical Mutual of Ohio Corporation
Minnesota
Molina Health Care, Inc.
Last verified: Apr 19, 2024Molina - Wisconsin Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Washington Specialty Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Washington Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina- Utah Medical Benefit Drug Prior Authorization Form Last verified: Apr 19, 2024Molina - Utah Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - South Carolina Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Ohio Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Mississippi Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Michigan Medicare Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Michigan Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Kentucky Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Illinois Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Idaho Medical Benefit Drug Prior Authorization Form Last verified: Apr 19, 2024Molina - Idaho Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - Florida Pharmacy Prior Authorization Form Last verified: Apr 19, 2024Molina - California Medical Benefit Drug Prior Authorization Form