Prior Authorization Forms
Drugs requiring prior authorization and their billing codes
| Orencia | J0129 |
| Remicade | J1745 |
Hyaluronic Acid Derivatives
| Euflexxa | J7323 |
| Hyalgan | J7321 |
| Orthovisc | J7324 |
| Supartz | J7321 |
| Synvisc | J7322 |
Please click the links below to download useful forms and information.
- CPAP/BiPAP Machine Prior
Authorization Request Form
- CPT Codes
for Imaging Services Requiring Prior Authorization
- Documentation
to Support the Use of Wheelchair Van Services
- Durable Medical Equipment (DME)
Medical Supply Prior Authorization Request
- Gastric
Bypass Surgery Prior Authorization Request
- Hospital
Discharge Notification form
- Incontinence
Products Authorization Form
-
Medical Equipment Request Evaluation Form - Non-Wheelchair
- Mobility Evaluation
Form
- Out of State Inpatient
Prior Authorization form
- Panniculectomy
Prior Authorization Request
- Pregnancy Notification
Form
- Prior Authorization Request
Form for Diagnostic Imaging
- Prior Authorization
Request Form for Hyaluronic Acid Derivatives
- Prior Authorization Request
Form for Remicade® for IBD Syndrome
- Prior Authorization
Request Form for Rheumatoid Arthritis Medication
-
Reduction Mammaplasty Prior Authorization Request
- Request for Prior Authorization
-
Request For Prior Authorization In Excess Of Service Limits
- Request for Prior Authorization
in Excess of Service Limits - Psychotherapy Services