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Submit via fax using the form below.

Please download the applicable request form below and fax it to 1-888-671-5285 or email it to us.* Please refer to your plan specific website to access the plan formulary.

If a drug specific form is not listed in the A-Z section, please select the "Other" section which has the general fax form and other administrative forms.

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A-Z drug-specific forms

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

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