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Zilretta prior authorization forms by payer

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

Arizona

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Arkansas Blue Cross Blue Shield

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Blue Cross Blue Shield of Arizona, Inc.

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Blue Cross Blue Shield of Massachusetts

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Blue Cross Blue Shield of Michigan

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Blue Cross Blue Shield of Tennessee

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Blue Cross of Idaho Health Services, Inc.

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Cigna Corporation

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Colorado

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CVS Caremark

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CVS Health (Aetna)

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Express Scripts (ESI)

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Hawaii

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Health Partners Plans

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Highmark, Inc.

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Last verified: Feb 01, 2024Highmark BCBS Northeastern NY - Medical Injectable Specialty Drug Prior Authorization FormLast verified: Feb 01, 2024Highmark BCBS Northeastern NY - Outpatient Chemotherapy Prior Authorization Form (Medical Benefit)Last verified: Feb 01, 2024Highmark BCBS Northeastern NY - Specialty Drug Prior Authorization FormLast verified: Feb 01, 2024Highmark BCBS Northeastern NY - Non-Formulary Drug Coverage Prior Authorization FormLast verified: Feb 01, 2024Highmark BCBS Northeastern NY - Medicare Specialty Drug Request FormLast verified: Feb 01, 2024Highmark BCBS Northeastern NY - Medicare Prescription Drug Medication Request Form Last verified: Feb 01, 2024Highmark BCBS Northeastern NY - Short Acting Opioid Prior Authorization FormLast verified: Feb 01, 2024Highmark BCBS Northeastern NY - Extended Release Opioid Prior Authorization FormLast verified: Feb 01, 2024Highmark BCBS Northeastern NY - Chronic Inflammatory Diseases Prior Authorization FormLast verified: Feb 01, 2024Highmark BCBS Western NY - Specialty Drug Prior Authorization Form Last verified: Feb 01, 2024Highmark BCBS Western NY - Non-Formulary Drug Coverage Prior Authorization Form Last verified: Feb 01, 2024Highmark BCBS Western NY - Medicare Specialty Drug Request FormLast verified: Feb 01, 2024Highmark BCBS Western NY - Medicare Prescription Drug Medication Request Form Last verified: Feb 01, 2024Highmark BCBS Western NY - Chronic Inflammatory Diseases Prior Authorization Form Last verified: Feb 01, 2024Highmark BCBS Western NY - Extended Release Opioid Prior Authorization Form Last verified: Feb 01, 2024Highmark BCBS Western NY - Short Acting Opioid Prior Authorization Form Last verified: Feb 01, 2024Highmark BCBS Western NY - Outpatient Medical Injectable Specialty Drug Prior Authorization Form Last verified: Feb 01, 2024Highmark BCBS Western NY - Outpatient Chemotherapy Prior Authorization Form (Medical Benefit)Last verified: Jan 31, 2024Highmark BCBS West Virginia - Request for Drug Coverage from Pharmaceutical Management ProgramLast verified: Jan 31, 2024Highmark BCBS West Virginia - Chronic Inflammatory Diseases Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS West Virginia - Extended Release Opioid Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS West Virginia - Short Acting Opioid Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS West Virginia - Specialty Drug Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Delaware - Specialty Drug Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Delaware - Prescription Drug Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Delaware - Chronic Inflammatory Diseases Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Delaware - Extended Release Opioid Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Delaware - Short Acting Opioid Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS West Virginia - Outpatient Chemotherapy Prior Authorization Form (Medical Benefit)Last verified: Jan 31, 2024Highmark BCBS West Virginia - Medical Injectable Specialty Drug Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Delaware - Medical Injectable Specialty Drug Authorization Request FormLast verified: Jan 31, 2024Highmark BCBS Delaware - Outpatient Chemotherapy Prior Authorization Form (Medical Benefit)Last verified: Jan 31, 2024Highmark BCBS Central PA - Medical Injectable Specialty Drug Chemotherapy Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Central PA - Outpatient Chemotherapy Prior Authorization Form (Medical Benefit)Last verified: Jan 31, 2024Highmark BCBS Central PA - Chronic Inflammatory Diseases Drug Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Central PA - Extended Release Opioid Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Central PA - Non-Formulary Drug Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Central PA - Short Acting Opioid Prior Authorization Form Last verified: Jan 31, 2024Highmark BCBS Central PA - Specialty Drug Prior Authorization Form Last verified: Jan 30, 2024Highmark BCBS Western PA - Medical Injectable Specialty Drug Prior Authorization Form Last verified: Jan 30, 2024Highmark BCBS Western PA - Outpatient Chemotherapy Prior Authorization Form (Medical Benefit)Last verified: Jan 30, 2024Highmark BCBS Western PA - Specialty Drug Prior Authorization Form Last verified: Jan 30, 2024Highmark BCBS Western PA - Non-Formulary Drug Prior Authorization Form Last verified: Jan 30, 2024Highmark BCBS Western PA - Short Acting Opioid Prior Authorization Form Last verified: Jan 30, 2024Highmark BCBS Western PA - Extended Release Opioid Prior Authorization Form Last verified: Jan 30, 2024Highmark BCBS Western PA - Chronic Inflammatory Diseases Prior Authorization Form

Humana, Inc.

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Illinois

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Independent Health Association, Inc.

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Indiana

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Kaiser Foundation Health Plans, Inc.

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Louisiana

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Medica Health Plans

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Medical Mutual of Ohio Corporation

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Michigan

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Minnesota

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Molina Health Care, Inc.

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MVP Health Care, Inc.

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New Hampshire

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New Mexico

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OptumRx

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Oregon

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PacificSource Health Plan

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Premera, Inc.

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Providence Health System

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Texas

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