Pharmacy Authorization Forms

Click "ctrl + f" and type in the name of the drug to search.                                                                           

Common Formulary Prior Authorization Request Form

Aetna's Universal Pharmacy Prior Authorization Fax Form

                                         

Benznidazole                                                          

Biologic Immunomodulators 

Corlanor  

Daraprim                                                      

Desmopressin  

Egrifta 

Elmiron  

Emflaza                                 

Growth Hormones  

Hematopoietic Agents 

Idiopathic Pulmonary Fibrosis

Lariam

Multiple Sclerosis Agents

Opioids and MME (opioid naive member for more than a 7-day supply of preferred and non-preferred agents) 

Opioids Long-acting and Transdermal (non-preferred agents) 

Opioids Short and Intermediate Acting (non-preferred agents)                                          

Opioid Withdrawal (Lucemyra)  

Oxbryta  

Oxervate                                                                                             

 

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591

PCN: ADV

Group: RX8826