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Rebif Prior Authorization Resources

Get the latest prior authorization forms for Medicare, Medicaid, and commercial plans, as well as state and medication-specific forms.

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Prior Authorization Forms

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Arkansas Blue Cross Blue Shield

Last verified: Dec 10, 2025Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form

Blue Cross Blue Shield of Tennessee

Last verified: Dec 11, 2025Blue Cross Blue Shield of Tennessee - Specialty Pharmacy Prior Authorization Form

Blue Cross of Idaho Health Services, Inc.

Last verified: Dec 10, 2025Blue Cross of Idaho - General Prior Authorization Form

California

Last verified: Dec 30, 2025California - Uniform Prior Authorization Form

Capital District Physicians Health Plan, Inc.

Last verified: Dec 10, 2025CDPHP - General Prior Authorization Form

Cigna Corporation

Last verified: Jan 02, 2026Cigna - Multiple Sclerosis Drugs Prior Authorization Form

Last verified: Dec 10, 2025Cigna - General Injectables Prior Authorization Form

Last verified: Dec 10, 2025Cigna - General Medication Prior Authorization Form

Colorado

Last verified: Dec 30, 2025Colorado - Uniform Prior Authorization Form

Curative Health Insurance

Last verified: Dec 10, 2025Curative Health Insurance - Prior Authorization Form

CVS Caremark

Last verified: Dec 10, 2025Caremark - Formulary Exception and Prior Authorization Form

CVS Health (Aetna)

Last verified: Dec 10, 2025Aetna - Oregon Prior Authorization/Medical Exception/Precertification Form

Last verified: Dec 10, 2025Aetna - Arizona Prior Authorization Form

Last verified: Dec 10, 2025Aetna - New Hampshire Prior Authorization Form

Last verified: Dec 10, 2025Aetna - Texas Prior Authorization Form

Last verified: Dec 10, 2025Aetna - Medicare Prescription Drug Coverage Determination

Last verified: Dec 10, 2025Aetna - California Prior Authorization Form

Last verified: Dec 10, 2025Aetna - Iowa Prior Authorization/Medical Exception/Precertification Request Form

Last verified: Dec 10, 2025Aetna - Illinois Prior Authorization Request Form

Last verified: Dec 10, 2025Aetna - Medical Exception/Prior Authorization/Precertification Request for Prescription Medications

Last verified: Dec 10, 2025Aetna - Louisiania Prior Authorization Request Form

Last verified: Dec 10, 2025Aetna - New York Contraceptive Exemption Request Form

Health Partners Plans

Last verified: Dec 10, 2025Health Partners - General Prior Authorization Form

Humana, Inc.

Last verified: Dec 10, 2025Humana - General Prior Authorization Form

Illinois

Last verified: Dec 30, 2025Illinois - Uniform Prior Authorization Form

Independent Health Association, Inc.

Last verified: Dec 10, 2025Independence Health - Medicare Part D Pharmacy Prior Authorization Form

Last verified: Dec 10, 2025Independence Health - Value Formulary Prior Authorization Form

Last verified: Dec 10, 2025Independence Health - Premium Formulary Prior Authorization Form

Last verified: Dec 10, 2025Independence Health - Select Formulary Prior Authorization Form

Indiana

Last verified: Dec 30, 2025Indiana - Uniform Prior Authorization Form

Kaiser Foundation Health Plans, Inc.

Last verified: Jan 02, 2026Kaiser Permanente - Mid Atlantic States HMO MS Nonpreferred Modestly Effective DMTs Prior Authorization Form

Last verified: Jan 02, 2026Kaiser Permanente - Maryland Health Choice MS Nonpreferred Modestly Effective DMTs Prior Authorization Form

Last verified: Dec 10, 2025Kaiser Permanente of Colorado HMO - Uniform Pharmacy Prior Authorization Request Form

Last verified: Dec 10, 2025Kaiser Permanente of Colorado - Medicare Medication Request form (MRF)

Louisiana

Last verified: Dec 30, 2025Louisiana - Uniform Prior Authorization Form

Medical Mutual of Ohio Corporation

Last verified: Dec 10, 2025Medical Mutual of Ohio - General Prior Authorization Form

Minnesota

Last verified: Dec 30, 2025Minnesota - Uniform Prior Authorization Form

Molina Health Care, Inc.

Last verified: Dec 10, 2025Molina - California Medical Benefit Drug Prior Authorization Form

Last verified: Dec 10, 2025Molina - Idaho Medical Benefit Drug Prior Authorization Form

Last verified: Dec 10, 2025Molina - Kentucky Pharmacy Prior Authorization Form

Last verified: Dec 10, 2025Molina - Utah Pharmacy Prior Authorization Form

Last verified: Dec 10, 2025Molina- Utah Medical Benefit Drug Prior Authorization Form

Last verified: Dec 10, 2025Molina - Wisconsin Pharmacy Prior Authorization Form

Last verified: Dec 10, 2025Molina - Washington Specialty Pharmacy Prior Authorization Form

Last verified: Dec 10, 2025Molina - Mississippi Pharmacy Prior Authorization Form

Last verified: Dec 10, 2025Molina - Idaho Pharmacy Prior Authorization Form

Last verified: Dec 10, 2025Molina - Ohio Pharmacy Prior Authorization Form

MVP Health Care, Inc.

Last verified: Dec 10, 2025MVP Health Care - Pharmacy Prior Authorization Form

Last verified: Dec 10, 2025MVP Health Care - NYS Medicaid Pharmacy Prior Authorization Form

Oregon

Last verified: Dec 30, 2025Oregon - Uniform Prior Authorization Form

PacificSource Health Plan

Last verified: Dec 10, 2025Pacific Source - Medicaid Community Solutions Prior Authorization Form

Last verified: Dec 10, 2025Pacific Source - Pharmacy Prior Authorization Form

Premera, Inc.

Last verified: Dec 10, 2025Premera - Pharmacy Prior Authorization Form

Providence Health System

Last verified: Dec 10, 2025Providence Health Plan - Drug Prior Authorization Form

Texas

Last verified: Dec 30, 2025Texas - Uniform Prior Authorization Form

Washington

Last verified: Dec 30, 2025Washington - Uniform Prior Authorization Form

Wisconsin

Last verified: Dec 30, 2025Wisconsin - Uniform Prior Authorization Form

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