Provider Forms

Drug Authorization Forms

• Medication Review Request Fax Cover
  Use this fax cover sheet if your authorization request was denied and you are requesting an appeal, or if you are requesting review for coverage of an excluded pharmacy product. Please note: This form is a cover sheet only. You are required to submit pertinent medical information that supports the pharmacy related request along with this fax cover form.
• Exception Request Form
  Use this form for requesting an exception when a drug authorization form is not available.