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Client Services > Group Benefits Plan Members > Forms > Prior Authorizations Forms

Prior Authorization Forms

Certain prescription drug claims need to be approved before we can consider reimbursement.

If your group benefits plan covers the drug you’re being prescribed and you want to be considered for coverage:

1. Select the Request for Information form, listed by drug name.

2. Print the form.

3. Ask your attending physician to complete it.

4. Send the completed form to us by mail or fax.

These documents are in PDF format. To view and print them, you need Adobe Acrobat Reader Version 4.0 or higher, which you can download, at no cost, from the Adobe website.

Request for Information forms

To find the appropriate form, select the first letter of the drug you’re being prescribed.

A    B    C    D    E    F    G    H    I    J    K    L    M    N    O    P    R    S    T    U    V    X    Y    Z


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L

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M

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N

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Questions?

Contact your plan administrator, or go to our Contact Information – Coverage and Claims Status page.

Need to Make Changes?

To update your personal information, contact your plan administrator.
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