Provider Waiver of Liability (WOL) Statement
Medical Admission Fax Cover Sheet
Refund Check Information Sheet* (RCIS)
Drug Prior Authorization Requests Supplied by the Physician/Facility
This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.
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.