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:

• Medicaid Cover Letter
• Medicaid Ancillary Provider Agreement
• W-9 Form

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:

• Medicaid Cover Letter
• Medicaid Participating Provider Agreement
• W-9 Form

Provider Resources

• Inpatient Fax Cover Letter
• Medication Appeal Request Form
• Medicaid Drug Coverage Request Form
• Notice of Pregnancy Form
• Provider Incident Report Form
• PCP Change Request Form for Prepaid Health Plans (PHPs)
• Provider Referral Form: LTSS Request for PCS Assessment
• Provider WW/Curves Baseline Fax Form
• Refund Check Information Sheet
• Value-Added Benefit Referral Form
• YMCA Provider Referral Form (Diabetes Prevention Program/Healthy Weight and Your Child)

Prior Authorization

• Prior Authorization Request (PDF)
• Pharmacy Prior Authorization Request: ASAP (PDF)
• Pharmacy Prior Authorization Request: A+ KIDS (PDF)
  

• Adulhelm
• Adulhelm Prior Approval Request
• Ankylosing Spondylitis (Enbrel, Humira, Simponi,Taltz)
• Antiemetics (Emend and Aprepitant)
• Antiparkinson’s Agents: Inbrija and Ongentys
• Austedo
• Cryopyrin-Associated Periodic Syndromes including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) (Arcalyst and Ilaris)
• Cialis
• Continuous Glucose Monitors
• Crinone 8% Gel
• Crohn’s Disease-Adult (Humira, Cimzia, Entyvio, Inflectra, Stelara, Remicade, Renflexis)
• Crohn’s Disease-Pediatric (Humira, Inflectra, Remicade, Renflexis)
• Cystic Fibrosis (Kalydeco, Orkambi, Symdeko, and Trikafta)
• Deficiency of Interleukin-1 Receptor Antagonist (DIRA) (Arcalyst and Kineret)
• Dupixent for Asthma
• Dupixent for Atopic Dermatitis
• Dupixent for Nasal Polyps 
• Emflaza
• Entresto
• Epclusa
• Epinephrine Pens
• Epidiolex 
• Evrysdi
• Exondys 51
• Familial Mediterranean Fever
• Fasenra
• Gattex
• Giant Cell Arteritis
• Gocovri and Osmolex ER
• Growth Hormone (Adult 21 Years of Age and Older)
• Growth Hormone (Children Less than 21 Years of Age)
• Harvoni
• Hematinics: Procrit/Epogen/Aranesp/Mircera/Retacrit
• Hetlioz/Hetlioz LQ
• Hidradenitis Suppurativa (Humira)
• HIDS MKD
• Immunomodulators: Cytokine Release Syndrome (Actemra Infusion and Actemra SQ)
• Ingrezza
• Ivermectin
• Juxtapid
• Lupus (Benlysta)
• Lupus (Lupkynis)
• Mavyret
• Migraine Calcitonin Agents (Ubrelvy and Nurtec)
• Migraine Calcitonin Gene Related Therapy Agents (Aimovig, Ajovy, Emgaltiy, Vyepti)
• Neonatal Onset Multi-System Inflammatory Disease - NOMID (Kineret)
• Neuromuscular Blocking Agents (Botox, Dysport, Myobloc, Xeomin)
• Neuromyelitis Optica Spectrum Disorder
• Non-Covered Request Form for Recipients under 21 Years Old
• Non Radiographic Axial Spondyloarthritis
• Non-Infectious Intermediate Posterior Panuveitis
• Nucala
• Opioid Analgesic (Long-Acting)
• Opioid Analgesic (Short-Acting)
• Opioid Dependence Therapy Agents
• Oral Ulcers
• PCSK9 Inhibitors
• Polyarticular Juvenile Idiopathic Arthritis (Enbrel, Humira, Actemra SQ, Actemra Infusion, Orencia Infusion and Orencia SQ)
• Plaque Psoriasis-Adult (Enbrel, Humira, Cosentyx, Cimzia, Ilumya, Inflectra, Otezla, Remicade, Renflexis, Siliq, Skyrizi, Stelara, Taltz, and Tremfya)
• Plaque Psoriasis-Pediatric (Enbrel and Stelara)
• Provigil and Nuvigil
• Psoriatic Arthritis (Enbrel, Humira, Inflectra, Cosentyx, Cimzia, Orencia, Orencia Infusion, Otezla, Renflexis, Remicade, Simponi, Simponia Aria, Stelara, Taltz, Xeljanz)
• Rheumatoid Arthritis (Enbrel, Humira, Actemra Infusion, Actemra SQ, Cimzia, Inflectra, Kevzara, Kineret, Olumiant, Orencia Infusion, Orencia SQ, Remicade)
• Sedative Hypnotics
• Selective Constipation Agents (Relistor)
• Systemic Onset Juvenile Idiopathic Arthritis (For Actemra SQ, Kineret and Ilaris)
• Sofosbuvir-Velpatasvir
• Standard Drug Request
• Sovaldi
• Stills Disease
• Sunosi
• Synagis
• Topical Local Anesthetics (Lidoderm Patch, lidocaine patch, and ZT Lido)
• Topical Anti-Inflammatory Medications
• Topical Antihistamines
• Topical Antifungal Agents (Vusion)
• Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) 
• Triptans
• Ulcerative Colitis (Adult)
• Ulcerative Colitis (Pediatric) Remicade
• Viekira
• Vosevi
• Vyondys 53 and Viltepso
• Wakix
• Xenazine and Tetrabenazine
• Xolair
• Xolair for Nasal Polyps
• Xyrem
• Xywav
• Zepatier
• Zolgensma