Forms
Access key forms for authorizations, claims, pharmacy and more.
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:
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:
Provider Resources
- Provider Incident Report Form
- PCP Change Request Form for Prepaid Health Plans (PHPs)
- Medication Appeal Request Form
- Refund Check Information Sheet
- YMCA Provider Referral Form (Diabetes Prevention Program/Healthy Weight and Your Child)
- Medicaid Drug Coverage Request Form
- Notice of Pregnancy Form
- Inpatient Fax Cover Letter
- Provider WW/Curves Baseline Fax Form
Prior Authorization Forms
- Medicaid Prior Authorization Request
- Medicaid Pharmacy Prior Authorization Request: ASAP
- Medicaid Pharmacy Prior Authorization Request: A+ KIDS
- Value-Added Benefit Referral Form
- 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