Forms
Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us.
Provider Services phone: (833) 685-2103
- Appeals and Reconsiderations
- Authorizations/Utilization Management
Prior Authorization Requests
- Notice of Decision, Behaviorally Complex Care Program Form
- Behavioral Health Prior Authorization Request Form and Instructions
- Prior Authorization Request Form and Instructions
- 278 – Service Request for Review and Response
Prior Authorization Reconsiderations and Appeals
- Claims
- Credentialing/Contracting
- Pharmacy
- Pharmacy Prior Authorization Request Form
- Actemra® (tocilizumab)
- ADHD Treatment for Recipients Age 18 and Above
- ADHD Treatment for Recipients Under Age 18
- Antihemophilia Agents Prior Authorization Request Form
- Auvi-Q® Prior Authorization Request Form
- Calcitonin Gene-Related Peptide (CGRP) Inhibitor Medications Prior Authorization Request Form
- Cimzia® (certolizumab pegol)
- Compounded Medication Prior Authorization Request Form
- Continuous Glucose Monitors (CGMs) Prior Authorization Request Form
- COX-II Inhibitors
- Cystic Fibrosis Agents Prior Authorization Request Form
- Daliresp® Prior Authorization Request Form
- Doxepin Cream Prior Authorization Request Form
- Elidel® (pimecrolimus) Prior Authorization Request Form
- Epidiolex® (cannabidiol) Prior Authorization Request Form
- Evenity® (romosozumab-aqqg) Prior Authorization Request Form
- Evrysdi® (risdiplam) Prior Authorization Request Form
- Exondys 51™ Prior Authorization Request Form
- Fintepla® (fenfluramine) Prior Authorization Request Form
- Forteo® (teriparatide) Prior Authorization Request Form
- Growth Hormone for Recipients Under Age 21
- Hematopoietic/Hematinic Agents Prior Authorization Request Form
- Hepatitis C Agents Prior Authorization Request Form
- High Dollar Claim Prior Authorization Form
- Immunomodulator Drugs Prior Authorization Request Form
- Insulin Pump Prior Authorization Request Form
- Kineret® (anakinra)
- Lidocaine Patch (Lidoderm®) Prior Authorization Request Form
- Lupron® Prior Authorization Request Form
- Medications for Recipients on Hospice Prior Authorization Request Form
- Monoclonal Antibody Agents Prior Authorization Request Form
- Multiple Sclerosis Agents Prior Authorization Request Form
- Multiple Sclerosis – Ampyra®
- Nayzilam® Prior Authorization Request Form
- Opioids Prescribed to Under Age 18 Prior Authorization Request Form
- Opioid Quantity Limit
- Oral Oncology Agents Prior Authorization Request Form
- Orencia® (abatacept)
- Oriahnn® (elagolix, estradiol and norethindrone) Prior Authorization Request Form
- Orilissa® (elagolix) Prior Authorization Request Form
- Prolia® (denosumab) Prior Authorization Request Form
- Protopic® (tacrolimus) Prior Authorization Request Form
- Psychotropic Agents for Children Age 0 to 5
- Psychotropic Agents for Children and Adolescents Ages 6 to 18
- Pulmonary Arterial Hypertension Agents Prior Authorization Request Form
- Qutenza® (capsaicin) Prior Authorization Request Form
- Remicade® (infliximab)
- Short-Acting Bronchodilator Quantity Limit Prior Authorization Request Form
- Simponi® (golimumab)
- Somavert® (pegvisomant) Prior Authorization Request Form
- Spinraza® Prior Authorization Request Form
- Stelara® (ustekinumab)
- Sunosi® Prior Authorization Request Form
- Synagis® Authorization Request Form
- Third Generation Cephalosporins and Fluoroquinolone Prior Authorization Request Form
- Topical Androgen Agents
- Tymlos® (abaloparatide) Prior Authorization Request Form
- Valtoco® (diazepam) Prior Authorization Request Form
- Vyondys 53® (golodirsen) Prior Authorization Request Form
- Wakix® (pitolisant) Medications Prior Authorization Request Form
- XyostedTM Prior Authorization Request Form
- Zelnorm® Prior Authorization Request Form
- Zeposia® (ozanimod) Prior Authorization Request Form
- Zyvox® (Linezolid ) Prior Authorization Request Form
- Women’s Health Services
Abortion Forms
- Other Forms