Pharmacy Prior Authorization Forms

• wpa/ nepa
• cpa/ sepa
• de
• wny
• neny

Addyi Prior Authorization Form

Aimovig Prior Authorization Form

Ajovy Prior Authorization Form

Armodafinil Prior Authorization Form

Blood Disorders Medication Request Form

Chronic Inflammatory Diseases Medication Request Form

Contrave Prior Authorization Form

Diabetic Testing Supplies Request Form

Dificid Prior Authorization Form

Dupixent Prior Authorization Form

Emgality Prior Authorization Form

Medicare Part D Hospice Prior Authorization Information

• wpa/ nepa
• cpa/ sepa
• de
• wny
• neny

Modafinil Prior Authorization Form

Opioid Prior Authorization Form

• wpa/ nepa
• cpa/ sepa
• wny
• neny

Prescription Drug Medication Request Form

• de

Prescription Drug Medication Request Form

• This form can be used to request a step therapy exception. For more information, read our Special Bulletin.

• wpa/ nepa
• cpa/ sepa
• de
• wny
• neny

Praulent Prior Authorization Form

Qsymia Prior Authorization Form

Repatha Prior Authorization Form

Saxenda Prior Authorization Form

Specialty Drug Request Form

Sunosi Prior Authorization Form

Testosterone Product Prior Authorization Form

Transplant Rejection Prophylaxis Medication Prior Authorization Form

Vyleesi Prior Authorization Form

Wegovy Prior Authorization Form

Xenical Prior Authorization Form

Zepbound Prior Authorization Form

• wv

For Members

Some types of health care services and supplies require prior authorization from Highmark before you can receive them. For additional information on prior authorization click Authorization Guidance.

Forms Removed

Effective July 1, 2024, West Virginia Law (Senate Bill 267) mandates the electronic submission of prior authorization requests. For this reason, Highmark removed West Virginia prior authorization forms from the Provider Resource Center (PRC). All prior authorization requests must now be submitted to Highmark via our provider portal (Availity®).