To submit a prior authorization online, please click the button below to use the web form.
PDF forms are available below to submit a prior authorization through fax.
FDA Medwatch Form
1 file(s) 1015 downloads
|BCBSAL, BCBSFL, HiLab, HWMG, RxBenefits, sscripts||May 14, 2019||Download|
Louisiana Prior Authorization Form
1 file(s) 1434 downloads
|RxBenefits||April 10, 2019||Download|
RxBenefits Prior Authorization Request Form
1 file(s) 7933 downloads
|RxBenefits||August 27, 2019||Download|