Provider Forms and Documents

General Forms

Behavioral Health

Additional program information coming soon.

Applied Behavior Analysis (ABA) Initial Treatment Request Forms:

Pharmacy

Physicians can access, complete and submit Prior Authorization and Step Therapy request forms electronically from the CoverMyMeds® website:

Pharmacy Drug:

Pharmacy Predetermination Physician Fax Forms:

Prime Specialty Pharmacy Referral:

Predeterminations (formerly called Prior Authorization) and Pre-Authorization/Precertification