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Prior Authorization Forms

Select the tab that contains the form you would like to view/download below. Prior authorization forms are organized alphabetically.

Prescribers can submit requests for prior authorization by completing the appropriate form below and submitting, via fax to ProAct, at 1-844-712-8129.

Please chose the appropriate medication/category-specific form below. If a specific form is not available please use the “General Prior Authorization Request” form. As regular updates will be made to these forms, choosing the correct form will result in the most efficient review of the request.

Please note: Prior authorization forms submitted are subject to validation against both member-specific prescription drug coverage and clinical criteria guidelines. Decisions regarding coverage determinations will be communicated to the appropriate parties once the review has been completed