Applications and forms for healthcare professionals and their patients.
It's easy to update a provider address, phone number, fax number, email address or initiate an out-of-state move or a change in provider group.
For Part D prior authorization forms, please see the Medicare section.
Authorized Representative Request (PDF)
Medicare Member Authorization Appeal-appealing Medicare denials of medical prior authorization (precertification) requests (PDF)
Medicare Non-contracted Provider Appeal Process (PDF)
Medicare Appeals Provider Memo- Post Service (PDF)
Member Complaint and Appeal (PDF)
Practitioner and Provider Complaint and Appeal (PDF)
Autolougous Chondrocyte Implantation (PDF)
Breast Reduction and/or Reconstructive Surgery (PDF)
Dorsal Column Stimulator (PDF)
Electroencephalographic (EEG) Video Monitoring (PDF)
Gender Reassignment Surgery (PDF)
Gender Reassignment Surgery - Aetna Student Health (PDF)
Hip Surgery for Impingement Syndrome (PDF)
Hyperbaric Oxygen Therapy (HBOT) (PDF)
Initial Cochlear Implant (PDF)
Lower Limb Prosthesis including Microprocessor-Controlled Knee (PDF)
Precertification Information Request Form (PDF)
Proton Beam Radiotherapy (PDF)
Skilled Home Private Duty Nursing Care (PDF)
Uvulopalatopharyngoplasty (UPPP) (PDF)
Standard Organization Determination Information Request Form
Hospital Discharge Appeal Notices
(Note: This is a page on the CMS site that provides information about patient rights as a hospital inpatient. The page includes detailed information and links to CMS forms.)
Part D prescription drug prior authorizations and exceptions
General prescription drug coverage determination (PDF)
General prescription drug coverage determination (through SilverScript)
Aranesp® (darbepoetin alfa) (PDF)
Lidocaine Products (generic Lidoderm®) (PDF)
Linezolid (generic Zyvox®) (PDF)
Modafinil and Armodafinil (generic Provigil®) (PDF)
Oral ondansetron (oral generic Zofran®) (PDF)
Sildenafil (generic Revatio®) (PDF)
Zolpidem tartrate (generic Ambien® immediate release) (PDF)
Abraxane® (albumin-bound paclitaxel) Medicare (PDF)
Actemra® (Tocilizumab) Medicare (PDF)
ADAKVEO® (crizanlizumab) Medication Precertification Request (PDF)
Adcetris® (Brentuximab Vedotin) Injectable Medication Precertification Request (PDF)
Aldurazyme® (laronidase) Medication Precertification Request (PDF)
Alpha 1 Antitrypsin Inhibitor Therapy Precertification Request (PDF)
Avsola (infliximab-axxq) Precertification Request (PDF)
Aveed Medication Precertification Request (PDF)
Bavencio® (Avelumab) Medication Precertification Request (PDF)
Bendamustine (Treanda®, Bendeka®, Belrapzo™) Medication Precertification Request (PDF)
Benlysta® (Belimumab) Injectable Medication Precertification Request (PDF)
Beovu® (brolucizumab-dbll) Injectable Medication Medicare Precertification Request (PDF)
Berinert® (C1 esterase inhibitor, human) Medication Precertification Request (PDF)
Besponsa®(Inotuzumab Ozogamicin) Medication Precertification Request (PDF)
Botulinum Toxins Medicare (PDF)
Brineura® (cerliponase alfa) Medication Precertification Request (PDF)
Cerezyme® (imiglucerase) Medication Precertification Request (PDF)
Cimzia® (Certolizumab) Precertification Request (PDF)
Cinqair® (Reslizumab) Medication Precertification Request (PDF)
Cinryze® (C1 esterase inhibitor, human) Medication Precertification Request (PDF)
Crysvita® (burosumab-twza) Injectable Medication Precertification Request (PDF)
Cyramza® (Ramucirumab) Medication Precertification Request (PDF)
DANYELZA® (naxitamab-gqgk) Medication Precertification Request (PDF)
Darzalex™ (Daratumumab) Medication Precertification Request (PDF)
Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) Medication Precertification Request (PDF)
Elaprase® (idursulfase) Medication Precertification Request (PDF)
Elelyso® (taliglucerase alfa) Medication Precertification Request (PDF)
Eligard® (leuprolide acetate suspension) Medication Precertification Request (PDF)
Emend® (Fosaprepitant) Injectable Medication Precertification Request (PDF)
Empliciti™ (Elotuzumab) Medication Precertification Request (PDF)
Enhertu® (fam-trastuzumab deruxtecan-nxki) Medication Precertification Request (PDF)
Entyvio® (Vedolizumab) Medicare (PDF)
Erbitux® (Cetuximab) Injectable medication precertification Request (PDF)
Erythropoiesis Stimulating Agents (ESAs) Medications Medicare (PDF)
Evenity® (Romosozumab) Medicare (PDF)
Eylea® (Aflibercept) Medicare (PDF)
Exondys51® (Eteplirsen) Injectable Precertification Request (PDF)
Fabrazyme® (agalsidase beta) Medication Precertification Request (PDF)
Fasenra™ (Benralizumab) Injectable Medication Precertification Request (PDF)
Firmagon® (degarelix) Medication Precertification Request (PDF)
Fulphila™ (pegfilgrastim-jmdb) Medicare (PDF)
Gattex® (Teduglutide) Injectable Medication Precertification Request (PDF)
Gazyva® (Obinutuzumab) Injectable Medication Precertification Request (PDF)
Gilenya® (Fingolimod) Medication Precertification Request (PDF)
Gilvaari™ (givosiran) Medication Precertification Request (PDF)
Granix® (tbo-filgrastim) Medicare (PDF)
Herceptin ® (Trastuzumab) Medicare Precertification Request (PDF)
Herzuma™ (trastuzumab-pkrb) Medicare Medication Precertification Request (PDF)
Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk) Medicare Precertification Request (PDF)
Ilaris® (Canakinumab) Injectable Medication Precertification Request (PDF)
Ilumya™ (Tildrakizumab) Medicare (PDF)
Imfinzi® (Durvalumab) Injectable Medication Precertification Request (PDF)
Imlygic™ (Talimogene Laherparepvec) Medication Precertification Request (PDF)
Inflectra® (Infliximab) Medicare (PDF)
Immune Globulin (IG) Therapy Medicare (PDF)
Jelmyto™ (mitomycin) Medication Precertification Request (PDF)
Kadcyla® (ado-trastuzumab) Medicare Precertification Request (PDF)
Kalbitor® (ecallantide) Medication Precertification Request (PDF)
Kanjinti (trastuzumab-anns) Medicare Precertification Request (PDF)
Kanuma® (sebelipase alfa) Medication Precertification Request (PDF)
Keytruda®(Pembrolizumab) Injectable Medication Precertification Request (PDF)
Lartruvo™ (Olaratumab) Medication Precertification Request (PDF)
Leukine® (sargramostim) Medication Precertification Request (PDF)
Lemtrada® (Alemtuzumab) Medicare (PDF)
Levoleucovorin (Fusilev®, Khapzory™) Injectable Medication Precertification Request (PDF)
Libtayo® (cemiplimab) Medication Precertification Request (PDF)
Lucentis® (Ranibizumab) Medicare (PDF)
Lumizyme® (alglucosidase alfa) Medication Precertification Request (PDF)
Lumoxiti™ (moxetumomab pasudotox)) Medication Precertification Request (PDF)
Lupron Depot® (leuprolide acetate for depot suspension) Medication Precertification Request (PDF)
Luxturna® (Voretigene Neparvovec-rzyl) Medication Precertification Request (PDF)
Macugen® (Pegaptanib Sodium) Injectable Medication Precertification Request (PDF)
Makena® (Hydroxyprogesterone Caproate) Medication Precertification Request (PDF)
MEPSEVII™ (vestronidase alfa-vjbk) Medication Precertification Request (PDF)
MONJUVI™ (tafasitamab-cxix) Injectable Medication Precertification Request (PDF)
Naglazyme® (galsulfase) Medication Precertification Request (PDF)
Neulasta® (pegfilgrastim) Medicare (PDF)
Neupogen® (filgrastim) Medicare (PDF)
Nivestym™ (filgrastim-aafi) Medicare (PDF)
Nyvepria (pegfilgrastim-apgf) Precertification Request (PDF)
Nucala® (Mepolizumab) Injectable Medication Precertification Request (PDF)
Ocrevus™ (Ocrelizumab) Medication Precertification Request (PDF)
Ogivri™ (trastuzumab-dkst) Medicare Precertification Request (PDF)
Ontruzant® (trastuzumab-dttb) Medicare Medication Precertification Request (PDF)
Onpattro® (patisiran) Injectable Medication Precertification Request (PDF)
Opdivo® (Nivolumab) Injectable Medication Precertification Request (PDF)
Orencia® (Abatacept) Medicare (PDF)
Oxlumo™ (lumasiran) Medication Precertification Request (PDF)
Padcev™ (enfortumab vedotin-ejfv) Medication Precertification Request (PDF)
Parsabiv™ (Etelcalcetid) Medication Precertification Request (PDF)
Perjeta® (pertuzumab) Medicare Precertification Request (PDF)
Phesgo™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf) Medication Precertification Request (PDF)
Polivy Precertification Request (PDF)
Prolia®, Xgeva® (Denosumab) Medicare (PDF)
Provenge Medication Precertification Request (PDF)
Radicava™ (Edaravone) Medication Precertification Request (PDF)
Reblozyl® (luspatercept-aamt) Medication Precertification Request (PDF)
Remicade® (Infliximab) Medicare (PDF)
Pulmonary Arterial Hypertension (Infusible, Inhalation, or Injectable Medication) Medicare (PDF)
Renflexis® (Infliximab-abda) Medicare (PDF)
Rituxan® (Rituximab) Medicare (PDF)
Rituxan Hycela® (rituximab and hyaluronidase) Medication Precertification Request (PDF)
Ruconest® (C1 esterase inhibitor, recombinant) Medication Precertification Request (PDF)
Ruxience (rituximab-pvvr) Precertification Request (PDF)
Sandostatin® LAR (octreotide acetate) Medication Precertification Request (PDF)
Sarclisa® (isatuximab-irfc) Medication Precertification Request (PDF)
Signifor® (pasireotide) Medication Precertification Request (PDF)
Signifor® LAR (pasireotide) Medication Precertification Request (PDF)
Simponi Aria (golimumab) Precertification Request (PDF)
Soliris® (Eculizumab) Medication Precertification Request (PDF)
Somatuline Depot® (lanreotide) Medication Precertification Request (PDF)
Somavert® (pegvisomant) Medication Precertification Request (PDF)
Spinzara® (Nusinersen) Injectable Precertification Request (PDF)
Spravato™ (esketamine) Medication Precertification Request (PDF)
Stelara® (Ustekinumab) Medicare (PDF)
Strensiq® (asfotase alfa) Injectable Medication Precertification Request (PDF)
Synagis® (Palivizumab) Injectable Medication Precertification Request (PDF)
Takhzyro® (C1 esterase inhibitor, recombinant) Medication Precertification Request (PDF)
Tecentriq™ (Atezolizumab) Medication Precertification Request (PDF)
Tegsedi™ (inotersen) Medication Precertification Request (PDF)
Tepezza™ (teprotumumab-trbw) Medication Precertification Request (PDF)
Trazimera® (trastuzumab-qyyp) Medicare Precertification Request (PDF)
Trelstar® (triptorelin pamoate) Medication Precertification Request (PDF)
Tremfya® (Guselkumab) Medication Precertification Request (PDF)
Trodelvy™ (sacituzumab govitecan-hziy) Medication Precertification Request (PDF)
Truxima (rituximab-abbs) Precertification Request (PDF)
Tysabri® (Natalizumab) Medicare (PDF)
Udenyca™ (pegfilgrastim-cbqv) Precertification Request (PDF)
Ultomiris™ (ravulizumab-cwvz) Precertification Request (PDF)
Uplizna™ (inebilizumab-cdon) Medication Precertification Request (PDF)
Vectibix® (Panitumumab) Injectable medication precertification Request (PDF)
Viltepso™ (viltolarsen) Medication Precertification Request (PDF)
Vimizim® (elosulfase alfa) Medication Precertification Request (PDF)
Viscosupplementation Medications Medicare (PDF)
VPRIV® (velaglucerase alfa) Medication Precertification Request (PDF)
Vyepti™ (eptinezumab-jjmr) Medication Precertification Request (PDF)
Vyondys 53® (golodirsen) Injectable Medication Precertification Request (PDF)
Xofigo® (Radium-223 dichloride) Injectable Medication Precertification Request (PDF)
Xolair®(Omalizumab) Medication Precertification (PDF)
Yervoy® (Ipilimumab) Injectable Medication Precertification Request (PDF)
Zarxio® (filgrastim-sndz) Medication Precertification Request (PDF)
Ziextenzo (pegfilgrastim-bmez) Precertification Request (PDF)
Zoladex® (goserelin acetate) Medication Precertification Request (PDF)
Zolgensma Medication Precertification Request (PDF)
Zulresso™ (brexanolone) Medication Precertification Request (PDF)
Mail Service Order Form (English) (PDF)
Mail Service Order Form (Spanish) (PDF)
Prescription Medication Claim (English) (PDF)
Prescription Medication Claim (Spanish) (PDF)
Prescription Medication Precertification
Opioid addiction treatment: For Aetna’s commercial plans, there is no precertification required for buprenorphine products.
Part D forms: Please see the Medicare section of this page.
If your're retiring, moving out of state or changing provider groups, use this form to notify us. We'll need to terminate your existing agreement with us. If your're moving or changing jobs, you can sign a new agreement for your new practice or location.
This form will also update your information on the online provider directory.
Provider termination form and directory update
Actemra® (Tocilizumab) Precertification Request (PDF)
ADAKVEO® (crizanlizumab) Medication Precertification Request (PDF)
Adcetris® (Brentuximab Vedotin) Injectable Medication Precertification Request (PDF)
Aldurazyme® (laronidase) Medication Precertification Request (PDF)
Alpha 1 Antitrypsin Inhibitor Therapy Precertification Request (PDF)
AMONDYS 45™ (casimersen) Injectable Medication Precertification Request (PDF)
Aranesp® (darbepoetin alfa) Medication Precertification Request (PDF)
Aveed Medication Precertification Request (PDF)
Avsola™ (infliximab-axxq) Injectable Medication Precertification Request (PDF)
Bavencio®(Avelumab) Medication Precertification Request (PDF)
Bendamustine (Treanda®, Bendeka®, Belrapzo™) Medication Precertification Request (PDF)
Benlysta®(Belimumab) Injectable Medication Precertification Request (PDF)
Beovu® (brolucizumab-dbll) Injectable Medication Precertification Request (PDF)
Berinert® (C1 esterase inhibitor, human) Medication Precertification Request (PDF)
Besponsa®(Inotuzumab Ozogamicin) Medication Precertification Request (PDF)
Blenrep (belantamab mafodotin-blmf) Medication Precertification Request (PDF)
Brineura® (cerliponase alfa) Medication Precertification Request (PDF)
Botox® (onabotulinumtoxinA) Injectable Medication Precertification Request (PDF)
Cerezyme® (imiglucerase) Medication Precertification Request (PDF)
Cinqair® (Reslizumab) Medication Precertification Request (PDF)
Cinryze® (C1 esterase inhibitor, human) Medication Precertification Request (PDF)
Cosela™ (trilaciclib) Medication Precertification Request (PDF)
Crysvita® (burosumab-twza) Injectable Medication Precertification Request (PDF)
Cyramza® (Ramucirumab) Medication Precertification Request (PDF)
DANYELZA® (naxitamab-gqgk) Medication Precertification Request (PDF)
Darzalex™ (Daratumumab) Medication Precertification Request (PDF)
Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) Medication Precertification Request (PDF)
Diabetic Testing Supplies Prior Authorization Request Form (PDF)
Dysport® (abobotulinumtoxinA) Injectable Medication Precertification Request (PDF)
Elaprase® (idursulfase) Medication Precertification Request (PDF)
Elelyso® (taliglucerase alfa) Medication Precertification Request (PDF)
Eligard® (leuprolide acetate suspension) Medication Precertification Request (PDF)
Empliciti™ (Elotuzumab) Medication Precertification Request (PDF)
Enhertu® (fam-trastuzumab deruxtecan-nxki) Medication Precertification Request (PDF)
Entyvio® (Vedolizumab) Injectable Medication Precertification Request (PDF)
Epogen® -Procrit® -Retacrit™ (epoetin alfa) Medication Precertification Request (PDF)
Epoprostenol, FLOLAN, VELETRI® (epoprostenol) Medication Precertification Request (PDF)
Erbitux® (Cetuximab) Injectable medication precertification Request (PDF)
Evkeeza™ (evinacumab-dgnb) Medication Precertification Request (PDF)
Evrysdi™ (risdiplam) Medication Precertification Request (PDF)
Exondys51® (Eteplirsen) Injectable Precertification Request (PDF)
Eylea® (Aflibercept) Injectable Precertification Request (PDF)
Fabrazyme® (agalsidase beta) Medication Precertification Request (PDF)
Fasenra™ (Benralizumab) Injectable Medication Precertification Request (PDF)
Filgrastim Precertification Request (Neupogen®, Granix®, Nivestym®, Zarxio®) (PDF)
Firazyr® (icatibant injection) Medication Precertification Request (PDF)
Firmagon® (degarelix) Medication Precertification Request (PDF)
Gattex® (Teduglutide) Injectable Medication Precertification Request (PDF)
GilvaariTM (givosiran) Medication Precertification Request (PDF)
Haegarda® (C1 esterase inhibitor, human) Medication Precertification Request (PDF)
Herceptin® (trastuzumab) Precertification Request (PDF)
Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk) Precertification Request (PDF)
Herzuma™ (trastuzumab-pkrb) Medication Precertification Request (PDF)
H.P Acthar Gel (Repository Corticotropin) Medication Precertification Request (PDF)
Hyaluronates (Viscosupplementation) Injectable Medication Precertification Request (PDF)
Imfinzi® (Durvalumab) Injectable Medication Precertification Request (PDF)
Imlygic™ (Talimogene Laherparepvec) Medication Precertification Request (PDF)
Immune Globulin (IG) Therapy Medication Precertification Request (PDF)
Infertility Medication Precertification Request (Female) (PDF)
Infertility Medication Precertification Request (Male) (PDF)
Inflectra® (Infliximab) Injectable Medication Precertification Request (PDF)
Jelmyto™ (mitomycin) Medication Precertification Request (PDF)
Kadcyla® (ado-trastuzumab) Precertification Request (PDF)
Kalbitor® (ecallantide) Medication Precertification Request (PDF)
Kanjinti™ (trastuzumab-anns) Precertification Request (PDF)
Kanuma® (sebelipase alfa) Medication Precertification Request (PDF)
Keytruda®(Pembrolizumab) Injectable Medication Precertification Request (PDF)
Lartruvo™ (Olaratumab) Medication Precertification Request (PDF)
Lemtrada® (Alemtuzumab) Medication Precertification Request (PDF)
Leukine® (sargramostim) Medication Precertification Request (PDF)
Levoleucovorin (Fusilev®, Khapzory™) Injectable Medication Precertification Request (PDF)
Libtayo® (cemiplimab) Medication Precertification Request (PDF)
Lucentis® (Ranibizumab) Injectable Medication Precertification Request (PDF)
Lumizyme® (alglucosidase alfa) Medication Precertification Request (PDF)
Lumoxiti™ (moxetumomab pasudotox)) Medication Precertification Request (PDF)
Lupron Depot ® (leuprolide acetate for depot suspension) Medication Precertification Request (PDF)
Luxturna ® (Voretigene Neparvovec-rzyl) Medication Precertification Request (PDF)
Macugen® (Pegaptanib Sodium) Injectable Medication Precertification Request (PDF)
Makena® (Hydroxyprogesterone Caproate) Medication Precertification Request (PDF)
MEPSEVII™ (vestronidase alfa-vjbk) Medication Precertification Request (PDF)
Miacalcin® (Calcitonin) Medication Precertification Request (PDF)
Mircera® (methoxy polyethylene glycol-epoetin beta) Medication Precertification Request (PDF)
MONJUVI™ (tafasitamab-cxix) Injectable Medication Precertification Request (PDF)
Myalept® (Metreleptin) Injectable Medication Precertification Request (PDF)
Myobloc® (rimabotulinumtoxinB) Injectable Medication Precertification (PDF)
Naglazyme® (galsulfase) Medication Precertification Request (PDF)
Natpara® (parathyroid hormone) Medication Precertification Request (PDF)
Nucala® (Mepolizumab) Injectable Medication Precertification Request (PDF)
Nulibry™ (fosdenopterin) Medication Precertification Request (PDF)
Ocrevus™(Ocrelizumab) Medication Precertification Request (PDF)
Ogivri™ (trastuzumab-dkst) Precertification Request (PDF)
Onpattro® (patisiran) Injectable Medication Precertification Request (PDF)
Ontruzant® (trastuzumab-dttb) Medication Precertification Request (PDF)
Opdivo® (Nivolumab) Injectable Medication Precertification Request (PDF)
Orencia® (Abatacept) Precertification Request (PDF)
Oxlumo™ (lumasiran) Medication Precertification Request (PDF)
Padcev™ (enfortumab vedotin-ejfv) Medication Precertification Request (PDF)
Parsabiv™ (Etelcalcetid) Medication Precertification Request (PDF)
Pegfilgrastim Precertification Request (Neulasta®, Fulphila®, Udenyca®, Ziextenzo®) (PDF)
Perjeta® (pertuzumab) Precertification Request (PDF)
Pepaxto® (melphalan flufenamide) Medication Precertification Request (PDF)
Phesgo™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf) Medication Precertification Request (PDF)
Polivy Precertification Request (PDF)
Prolia® (denosumab) Injectable Medication Precertification Request (PDF)
Provenge Medication Precertification Request (PDF)
Radicava™ (Edaravone) Medication Precertification Request (PDF)
Reblozyl® (luspatercept-aamt) Medication Precertification Request (PDF)
Remicade® (Infliximab) Precertification Request (PDF)
Remodulin® (treprostinil) Medication Precertification Request (PDF)
Renflexis ® (Infliximab-abda) Injectable Medication Precertification Request (PDF)
Rituxan Hycela® (rituximab and hyaluronidase) Medication Precertification Request (PDF)
Rituxan® (Rituximab) Precertification Request (PDF)
Ruconest® (C1 esterase inhibitor, recombinant) Medication Precertification Request (PDF)
Ruxience™ (rituximab-pvvr) Medication Precertification Request (PDF)
Sarclisa® (isatuximab-irfc) Medication Precertification Request (PDF)
Signifor® (pasireotide) Medication Precertification Request (PDF)
Signifor® LAR (pasireotide) Medication Precertification Request (PDF)
Simponi Aria® (Golimumab) Infusion Medication Precertification Request (PDF)
Soliris® (Eculizumab) Medication Precertification Request (PDF)
Somatuline Depot® (lanreotide) Medication Precertification Request (PDF)
Somavert® (pegvisomant) Medication Precertification Request (PDF)
Spinzara® (Nusinersen) Injectable Precertification Request (PDF)
Spravato™ (esketamine) Medication Precertification Request (PDF)
Stelara® (Ustekinumab) Precertification Request (PDF)
Strensiq® (asfotase alfa) Injectable Medication Precertification Request (PDF)
Synagis® (Palivizumab) Injectable Medication Precertification Request (PDF)
Takhzyro® (C1 esterase inhibitor, recombinant) Medication Precertification Request (PDF)
Tecentriq™ (Atezolizumab) Medication Precertification Request (PDF)
Tegsedi™ (inotersen) Medication Precertification Request (PDF)
Tepezza™ (teprotumumab-trbw) Medication Precertification Request (PDF)
Trazimera® (trastuzumab-qyyp) Precertification Request (PDF)
Trelstar® (triptorelin pamoate) Medication Precertification Request (PDF)
Trodelvy™ (sacituzumab govitecan-hziy) Medication Precertification Request (PDF)
Truxima™ (rituximab-abbs) Medication Precertification Request (PDF)
Tysabri® (Natalizumab) Medication Precertification Request (PDF)
Tyvaso® (treprostinil inhalation solution) Medication Precertification Request (PDF)
Ultomiris™ (ravulizumab-cwvz) Precertification Request (PDF)
Uplizna™ (inebilizumab-cdon) Medication Precertification Request (PDF)
Vectibix® (Panitumumab) Injectable medication precertification Request (PDF)
Viltepso™ (viltolarsen) Medication Precertification Request (PDF)
Ventavis® (iloprost inhalation solution) Medication Precertification Request (PDF)
Vimizim® (elosulfase alfa) Medication Precertification Request (PDF)
VPRIV® (velaglucerase alfa) Medication Precertification Request (PDF)
Vyepti™ (eptinezumab-jjmr) Medication Precertification Request (PDF)
Vyondys 53® (golodirsen) Injectable Medication Precertification Request (PDF)
Xeomin® (incobotulinumtoxinA) Injectable Medication Precertification Request (PDF)
Xgeva® (denosumab) Injectable Medication Precertification Request (PDF)
Xofigo® (Radium-223 dichloride) Injectable Medication Precertification Request (PDF)
Xolair®(Omalizumab) Medication Precertification (PDF)
Yervoy® (Ipilimumab) Injectable Medication Precertification Request (PDF)
Zoladex® (goserelin acetate) Medication Precertification Request (PDF)
Zolgensma Medication Precertification Request (PDF)
Zulresso™ (brexanolone) Medication Precertification Request (PDF)
Specialty Medication Precertification Request Form (General) (PDF)
California Prescription Drug Prior Authorization (PDF)
Colorado Prescription Drug Prior Authorization (PDF)
Connecticut Accident Detail Questionnaire (PDF)
Iowa Prescription Drug Prior Authorization (PDF)
Louisiana Prescription Drug Prior Authorization (PDF)
Massachusetts Standard Prior Authorization Forms
Michigan Prescription Drug Prior Authorization (PDF)
New Hampshire Prescription Drug Prior Authorization (PDF)
New Jersey Appeal a Claim Determination (PDF)
New Mexico Uniform Prior Authorization (PDF)
New York Contraceptive Exception Request (PDF)
Ohio Electronic Funds Transfer (EFT) Opt Out (PDF)
Oregon Prescription Drug Prior Authorization (PDF)
Texas Prescription Drug Prior Authorization (PDF)
Texas Standard Prior Authorization (PDF)
Texas Telemedicine and Telehealth Services Reimbursement Policy (PDF)
Washington Intent to Use a Substitute Provider (PDF)
Washington D.C. Uniform Consultation Referral (Appendix 43-1)
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