Workflow of a Request – Where the request needs to be sent.
Please go to Cover My Meds to initiate a request.
- Quantity Limit Exception Form [PDF]
- Exception Criteria Form [PDF] – For use with drugs that require a Prior Authorization, Quantity Limit, or are Non-Formulary
- Step Therapy Criteria Form [PDF] – For use with drugs that require Step Therapy
- Long Acting Opioid Prior Authorization Form [PDF]
- Short Acting Opioid Prior Authorization Form [PDF]
- Hepatitis C Prior Authorization Form [PDF]