Forms
Access and download forms to help you serve our members and do business with us. Bookmark this page and check back for updates to ensure you use the latest version.
Quick Links
Appeals and disputes
- Authorization appeal [PDF]
Contracted providers: Postservice appeal and claim dispute [PDF]
Noncontracted providers: Appeals and disputes [PDF]
Behavioral health
Network interest
Postacute clinical
Prior authorization
- Prior authorization request [PDF]
- Durable medical equipment fax request [PDF]
- Genetic testing request [PDF]
Home health care [PDF] (for Arizona only)
- Home health services [PDF]
- Orthopedic spine procedure [PDF]
- Revascularization procedure [PDF]
- Skilled nursing facility, inpatient rehab and long-term acute care [PDF]
- Transplant referral [PDF]
Pharmacy
Drugs/biologics Part B prior authorization [PDF]
Drugs/biologics Part B step therapy prior authorization:
- Actemra, Tofidence and Avtozma [PDF]
- Avastin, Vegzelma, Avzivi and Jobevne [PDF]
- Aveed, Testopel, Xyosted and Azmiro [PDF]
- Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Sodium Hyaluronate 1%, Supartz FX, SynoJoynt, Triluron, TriVisc and Visco-3 [PDF]
- Eylea, Eylea HD, Lucentis, Beovu, Vabysmo, Byooviz, Cimerli and Pavblu [PDF]
- Herceptin IV, Herceptin Hylecta, Herzuma, Ontruzant and Hercessi [PDF]
- Intravenous Immune Globulin − Alyglo, Asceniv, Bivigam, Panzyga and Yimmugo [PDF]
- Monoferric, Feraheme and Injectafer [PDF]
- Myobloc [PDF]
- Neupogen, Granix, Releuko and Nypozi [PDF]
- PCSK9 Inhibitors and Leqvio [PDF]
- Remicade [PDF]
- Rituxan and Rituxan Hycela [PDF]
- Sandostatin LAR [PDF]
- Saphnelo [PDF]
- Soliris, BKEMV [PDF]
- Stelara IV [PDF]
- Subcutaneous Immune Globulin − Cuvitru and Hyqvia [PDF]
- Vyepti [PDF]
- Ziextenzo, Nyvepria, Fylnetra, Stimufend, Rolvedon and Ryzneuta [PDF]