PBM Prior Authorization Forms Displaying 1 - 40 of 53 results. Name Aetna (Coventry Health) 539.51 KB .pdf Alluma 482.3 KB .pdf Benecard Services Inc 147.22 KB .pdf Capital RX, Inc. 424.14 KB .pdf Caremark Global 177.64 KB .pdf CastiaRx 355.17 KB .pdf CerpassRx 971.71 KB .pdf Change Healthcare Pharmacy Solutions 448.2 KB .pdf Cigna Health and Life Insurance Company 56.18 KB .pdf Costco 70.13 KB .pdf CVS/CAREMARK 177.64 KB .pdf DST Pharmacy Solutions 166.22 KB .pdf Elixir RX Solutions LLC 88.57 KB .pdf Express Scripts 123.65 KB .pdf FairosRX, LLC 169.32 KB .pdf Fairview Pharmacy Services LLC 172.15 KB .pdf Humana Pharmacy Solutions 97.18 KB .pdf Independent Health's Pharmacy Benefit Dimensions LLC 972.91 KB .pdf IngenioRX Inc 528.57 KB .pdf Kroger 202.89 KB .pdf Magellan Rx Management 1.8 MB .pdf MaxorPlus LTD 54 KB .pdf Medical Associates 8.46 KB .pdf MedImpact 234.68 KB .pdf MedOne 170.49 KB .pdf Navitus 31.49 KB .pdf NBFSA 394.42 KB .pdf OptumRx - Commercial for non-United Healthcare clients 193.34 KB .pdf OptumRx - United Healthcare commercial business 144.59 KB .pdf OptumRx - United Healthcare Government Programs Exchange 143.56 KB .pdf Oscar Insurance Company 97.84 KB .pdf PerformRX LLC 78.47 KB .pdf Pharmacy Data Management Inc 821.67 KB .pdf PharmaForce 177.43 KB .pdf Prime Therapeutics 355.94 KB .pdf ProAct Inc. 179.58 KB .pdf ProCare 116.14 KB .pdf Prodigy Care Services LLC 139.34 KB .pdf Quartz 149.27 KB .pdf Rightway 60.16 KB .pdf Pagination Current page 1 Page 2 Next page Next Last page Last
Displaying 1 - 40 of 53 results. Name Aetna (Coventry Health) 539.51 KB .pdf Alluma 482.3 KB .pdf Benecard Services Inc 147.22 KB .pdf Capital RX, Inc. 424.14 KB .pdf Caremark Global 177.64 KB .pdf CastiaRx 355.17 KB .pdf CerpassRx 971.71 KB .pdf Change Healthcare Pharmacy Solutions 448.2 KB .pdf Cigna Health and Life Insurance Company 56.18 KB .pdf Costco 70.13 KB .pdf CVS/CAREMARK 177.64 KB .pdf DST Pharmacy Solutions 166.22 KB .pdf Elixir RX Solutions LLC 88.57 KB .pdf Express Scripts 123.65 KB .pdf FairosRX, LLC 169.32 KB .pdf Fairview Pharmacy Services LLC 172.15 KB .pdf Humana Pharmacy Solutions 97.18 KB .pdf Independent Health's Pharmacy Benefit Dimensions LLC 972.91 KB .pdf IngenioRX Inc 528.57 KB .pdf Kroger 202.89 KB .pdf Magellan Rx Management 1.8 MB .pdf MaxorPlus LTD 54 KB .pdf Medical Associates 8.46 KB .pdf MedImpact 234.68 KB .pdf MedOne 170.49 KB .pdf Navitus 31.49 KB .pdf NBFSA 394.42 KB .pdf OptumRx - Commercial for non-United Healthcare clients 193.34 KB .pdf OptumRx - United Healthcare commercial business 144.59 KB .pdf OptumRx - United Healthcare Government Programs Exchange 143.56 KB .pdf Oscar Insurance Company 97.84 KB .pdf PerformRX LLC 78.47 KB .pdf Pharmacy Data Management Inc 821.67 KB .pdf PharmaForce 177.43 KB .pdf Prime Therapeutics 355.94 KB .pdf ProAct Inc. 179.58 KB .pdf ProCare 116.14 KB .pdf Prodigy Care Services LLC 139.34 KB .pdf Quartz 149.27 KB .pdf Rightway 60.16 KB .pdf Pagination Current page 1 Page 2 Next page Next Last page Last