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.
- ledipasvir/sofosbuvir (generic Harvoni)
- Lenvima
- Lidocaine patch
- Lidoderm
- Lonsurf
- Lopreeza
- Lorbrena
- Lorzone
- Lunesta
- Lynparza
Other forms
- General Fax Form
- B vs. D Fax Form
- Duplicate Long-Acting Opioid Use Form
- Hospice Fax Form
- Intradialytic Parenteral Nutrition (IDPN)/Intraperitoneal Nutrition (IPN)/Parenteral Nutrition (TPN) Form
- Morphine Equivalent Dose
- Opioid - 7 Days Supply Limit
- Opioid-APAP Combination Use Form
- Opioid-Benzodiazepine Combination Use Form
- Opioid-Medication Assisted Treatment (MAT) Combination Use Form
- Opioid-Prenatal Combination Use Form
- Tier Lowering Exception Form
Top