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