Prior Authorization Drug List and Forms

Prior Authorization Drug List and Forms

Please enter your group contract number to verify if your drug plan includes Prior Authorization. If you're not sure what your contract number is, please contact your Benefits Administrator.

Please choose the form you need from the list below. If the form doesn’t load, try using a different web browser. You can also save the form to your computer:

  1. Click the download icon in the upper right corner of the “Please wait” page.
  2. Save the form to your computer.
  3. Open the file from where you saved it on your computer.
Table containing drug list
Drug Category Drugs Prior Authorization Form