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Forms

Access key forms for authorizations, claims, pharmacy and more.

Appeals & Grievances

Authorizations

This request will be treated as per the standard organization determination time frames.

Drug Prior Authorization Requests Supplied by the Physician/Facility

Behavioral Health Forms

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

Below are the most commonly prescribed medications that were on the 2018 formulary and their preferred 2019 alternatives.

Drug Prior Authorization Requests Supplied by the Physician/Facility

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Other Provider Forms

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Last Updated On: 2/1/2019
Medicare and Prescription Drug Plan Members: A new and enhanced member portal will soon be available. This portal will offer a fresh homepage, all new billing and payment options for 2020, and more! Check back on 10/15 to see what else is new. ×