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Or give us a call at 1-800-279-1878 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 6 PM.
Pharmacy PA guidelines
Pharmacy PA guidelines
Non-formulary and PA guidelines (PDF)
Compounded Drug Products (PDF)
Continuous Glucose Monitor (PDF)
Epoprostenol-Flolan-Veletri (PDF)
Fentanyl - Oral and Intranasal (PDF)
Immune Globulin Intravenous (PDF)
Immune Globulin Subcutaneous (PDF)
Insomnia Agents - Dayvigo, Quviviq, Belsomra (PDF)
Lupron Depot Endometriosis - Fibroids (PDF)
Lupron Depot Prostate Cancer (PDF)
Neulasta and pegfilgrastim biosimilars (PDF)
Neupogen and filgrastim biosimilars (PDF)
Nitroglycerin 0.4 percent ointment (Rectiv) (PDF)
One Touch Diabetic Test Strips (PDF)
Ranolazine Extended Release (PDF)
Vyvgart - Vyvgart Hytrulo (PDF)
Zoledronic Acid - Reclast - Zometa (PDF)
Electronic PA (ePA)
Electronic PA (ePA)
You need the right tools and technology to help our members. That’s why we’ve partnered with CoverMyMeds® and Surescripts to provide a new way to request a pharmacy PA with our ePA program.
With ePA, you can look forward to saving time with:
Less paperwork
Fewer phone calls and faxes
Quicker determinations
Safe and secure HIPAA-compliant submitted requests
Easy upload of clinical documents
Enroll now
Getting started with ePA is free and easy. You’ll need this info to enroll:
- BIN: 610591
- GRP: RX8837
- PCN: ADV
You can enroll two different ways:
Other ways to request PA
If you don’t want to enroll in ePA, you can request PA:
By phone
Give us a call at 1-800-279-1878 (TTY: 711).
By fax
Check the “PA request forms” section below to find the right form. Then, fax it with any supporting documentation for a medical necessity review to 1-855-799-2553.
Request forms
If you don’t see the right form in the list, you can use the universal pharmacy PA fax form (PDF). Otherwise, check for the drug class or drug name that matches your needs:
ADD-ADHD medications age limit (PDF)
Atypical antipsychotics, less than 18 years (PDF)
Colony stimulating factors non-preferred (PDF)
Cytokine and CAM Antagonists (PDF)
GLP1 receptor agonists for cardiovascular risk reduction (PDF)
Hepatitis C non-preferred (PDF)
Hereditary angioedema agents (PDF)
Incretin Mimetics Non-Preferred (PDF)
CoverMyMeds is a registered trademark of CoverMyMeds LLC.