Buprenorphine/Naloxone and Subutex (Buprenorphine) PA Request Form

Epidiolex Clinical Criteria

General Fax PA Request Form

Hepatitis C Patient Commitment Form

Long Acting Injectable Atypical Antipsychotics PA Request Form

Mavyret PA Request Form

Morphine Milligram Equivalent (MME) PA Form

Opioid Use Disorder Medication-Assisted Treatment Policy

Preferred Drug Program PDL PA Form

Use this form to request authorization for your patient’s use of a non-preferred drug.

Synagis PA Request Form

Travel PA Request Form

Vivitrol POS Instructions

Vosevi PA Request Form

Xeloda PA Request Form