Access key forms for authorizations, claims, pharmacy and more.
Provider Waiver of Liability (WOL) Statement
This request will be treated as per the standard organization determination time frames.
Refund Check Information Sheet* (RCIS)
This list includes the most commonly prescribed medications that were on the 2016 formulary and their preferred 2017 alternatives.
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.