Prior Authorization and Appeal Forms

To assist us in a more efficient review, please search for the requested agent first to see if there is a custom prior authorization (PA) form. If the medication is not listed, please use the General PA form at the top!

Thank you for ensuring the correct form is submitted to facilitate a smooth review process!

General PA form

Continuous Glucose Monitoring (CGM) Agents: Dexcom, Freestyle Libre

CGRP Antagonists: Aimovig, Ajovy, Emgality, Nurtec ODT, Qulipta, Ubrelvy

GLP-1 Agonists:Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Tanzeum, Trulicity, Victoza

Immunomodulators: Actemra, adalimumab-fkjp, Bimzelx, Cibinqo, Cimzia, Cosentyx, Dupixent, Ebglyss, Enbrel, Entyvio, Fasenra, Hadlima, Humira, Hyrimoz, Ilumya, Kevzara, Kineret, Litfulo, Nemluvio, Nucala, Olumiant, Omvoh, Orencia, Otezla, Otulfi, Remicade, Rinvoq, Siliq, Simlandi, Simponi, Skyrizi, Sotyktu, Spevigo, Stelara, Taltz, Tezspire, Tremfya, Tyenne, Wezlana, Xeljanz, Xolair, Yusimry, Zymfentra
Please be aware that our preferred Humira biosimilars are adalimumab-fkjp, Hadlima, Simlandi, & Yusimry; Our preferred biosimilar for Stelara is Otulfi

Insulins: Apidra, Basaglar, Fiasp, Humalog, Insulin aspart, insulin degludec, insulin glargine, insulin glargine-yfgn, insulin lispro, Lantus, Levemir, Novolog, Rezvoglar, Semglee, Tresiba, Toujeo

PCSK9 Inhibitors: Praluent, Repatha

Weight Loss: Contrave, Qsymia, Xenical

Weight Management: Wegovy, Zepbound



Appeal Form

Formulary Exception Form

Upload Completed PA Form and Supporting Documents