Forms
Access key forms for authorizations, claims, pharmacy and more.
Ancillary Contract Packet
If you provide services such as home health, Personal care services, hospice, DME, Inpatient services and more, please download and complete the forms below:
Physician/Allied Contract Packet
If you provide services such as primary care, specialist care, mental health, substance abuse and more, please download and complete the forms below:
Provider Resources
- Prior Authorization Request Form (PDF)
- Inpatient Fax Cover Letter (PDF)
- Medication Appeal Request Form (PDF)
- Medicaid Drug Coverage Request Form (PDF)
- Notice of Pregnancy Form (PDF)
- Provider Incident Report Form (PDF)
- Provider Medical Abortion Consent Form (PDF)
- PCP Change Request Form for Prepaid Health Plans (PHPs) (PDF)
- PCP Transfer Request Form (PDF)
- Provider Referral Form: LTSS Request for PCS Assessment (PDF)
- Provider WW/Curves Baseline Fax Form (PDF)
- Refund Check Information Sheet (PDF)
- YMCA Provider Referral Form (Diabetes Prevention Program/Healthy Weight and Your Child) (PDF)
- Requesting Interpreter Services Form (PDF)
Pharmacy Prior Authorization Request Forms
A
- Pharmacy Prior Authorization Request: ASAP (PDF)
- Pharmacy Prior Authorization Request: A+ KIDS (PDF)
- Adulhelm (PDF)
- Adulhelm Prior Approval Request (PDF)
- Amondys 4 (PDF)
- Ankylosing Spondylitis (Enbrel, Humira, Simponi,Taltz (PDF)
- Antiemetics (Emend and Aprepitant) (PDF)
- Antiparkinson’s Agents: Inbrija and Ongentys (PDF)
- Austedo (PDF)
C
- Camzyos (PDF)
- Cryopyrin-Associated Periodic Syndromes including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) (Arcalyst and Ilaris) (PDF)
- Cialis (PDF)
- Continuous Glucose Monitors (PDF)
- Crinone 8% Gel (PDF)
- Crohn’s Disease-Adult (Humira, Cimzia, Entyvio, Inflectra, Stelara, Remicade, Renflexis (PDF)
- Crohn’s Disease-Pediatric (Humira, Inflectra, Remicade, Renflexis) (PDF)
- Cystic Fibrosis (Kalydeco, Orkambi, Symdeko, and Trikafta) (PDF)
D
- Deficiency of Interleukin-1 Receptor Antagonist (DIRA) (Arcalyst and Kineret) (PDF)
- Dupixent for Asthma (PDF)
- Dupixent for Atopic Dermatitis (PDF)
- Dupixent for Eosinophilic Esophagitis (PDF)
- Dupixent for Prurigo Nodularis (PDF)
- Dupixent for Nasal Polyps (PDF)
E
- Emflaza (PDF)
- Entresto (PDF
- Epinephrine Pens (PDF)
- Epclusa (PDF)
- Epidiolex (PDF)
- Evrysdi (PDF)
- Exondys 51 (PDF)
F
M
- Migraine Calcitonin Agents (Ubrelvy and Nurtec) (PDF)
- Migraine Calcitonin Gene Related Therapy Agents (Aimovig, Ajovy, Emgaltiy, Vyepti) (PDF)
- Monoclonal Antibodies (Adbry) (PDF)
- Monoclonal Antibodies (Tezspire) (PDF)
N
- Neonatal Onset Multi-System Inflammatory Disease - NOMID (Kineret) (PDF)
- Neuromuscular Blocking Agents (Botox, Dysport, Myobloc, Xeomin) (PDF)
- Neuromyelitis Optica Spectrum Disorder (PDF)
- Nexletol and Nexlizet (PDF)
- Non-Covered Request Form for Recipients under 21 Years Old (PDF)
- Non Radiographic Axial Spondyloarthritis (PDF)
- Non-Infectious Intermediate Posterior Panuveitis (PDF)
- Nucala (PDF)
O
- Opioid Analgesic (Long-Acting) (PDF)
- Opioid Analgesic (Short-Acting (PDF)
- Opioid Dependence Therapy Agents (PDF)
- Oral Ulcers (PDF)
P
- PCSK9 Inhibitors (PDF)
- Polyarticular Juvenile Idiopathic Arthritis (Enbrel, Humira, Actemra SQ, Actemra Infusion, Orencia Infusion and Orencia SQ) (PDF)
- Plaque Psoriasis-Adult (Enbrel, Humira, Cosentyx, Cimzia, Ilumya, Inflectra, Otezla, Remicade, Renflexis, Siliq, Skyrizi, Stelara, Taltz, and Tremfya) (PDF)
- Plaque Psoriasis-Pediatric (Enbrel and Stelara) (PDF)
- Provigil and Nuvigil (PDF)
- Psoriatic Arthritis (Enbrel, Humira, Inflectra, Cosentyx, Cimzia, Orencia, Orencia Infusion, Otezla, Renflexis, Remicade, Simponi, Simponia Aria, Stelara, Taltz, Xeljanz) (PDF)
R
G
- Giant Cell Arteritis (PDF)
- GLP-1 Receptor Agonists (PDF)
- Gocovri and Osmolex ER (PDF)
- Growth Hormone (Adult 21 Years of Age and Older) (PDF)
- Growth Hormone (Children Less than 21 Years of Age) (PDF)
H
- Harvoni (PDF)
- Hematinics: Procrit/Epogen/Aranesp/Mircera/Retacrit (PDF)
- Hereditary Angioedema (HAE) Agents (PDF)
- Hetlioz/Hetlioz LQ (PDF)
- Hidradenitis Suppurativa (Humira) (PDF)
- HIDS MKD (PDF)
I
- Immunomodulators: Cytokine Release Syndrome (Actemra Infusion and Actemra SQ) (PDF)
- Ingrezza (PDF)
- Ivermectin (PDF)
J
L
S
- Sedative Hypnotics (PDF)
- Selective Constipation Agents (Relistor) (PDF)
- SGLT2 Inhibitors and Combinations (PDF)
- Systemic Onset Juvenile Idiopathic Arthritis (For Actemra SQ, Kineret and Ilaris) (PDF)
- Standard Drug Request (PDF)
- Sovaldi (PDF)
- Stills Disease (PDF)
- Sunosi (PDF)
- Synagis (PDF)
T
- Topical Local Anesthetics (PDF)
- Topical Anti-Inflammatory Medications (PDF)
- Topical Antihistamines (PDF)
- Topical Antifungal Agents (Vusion) (PDF)
- Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) (PDF)
- Triptans (PDF)