Arizona Community Plan Pharmacy Prior Authorization Forms
To simplify your experience with prior authorization and save time, please submit your prior authorization request through the following online portals:
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Electronic Prior Authorization (ePA)
Submit an ePA using CoverMyMeds
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Electronic prior authorization (ePA)
Submit an ePA using SureScripts
Otherwise, you can submit requests by completing and faxing the applicable form below. You can search for a drug specific form by entering the requested drug in the search box below. If your search does not yield a result, please use this Prior Authorization Request form.
ADHD Products (Arizona) Prior Authorization Form - Community Plan
Last Published 02.22.2022
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Antipsychotics (Arizona) Prior Authorization Form - Community Plan
Last Published 02.21.2022
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Arizona Reinsurable Drug Program (Arizona) Prior Authorization Form - Community Plan
Last Published 02.22.2022
*** These products are part of the Arizona Reinsurable Drug List and are a pharmacy benefit.*** Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Dupixent (AZ, HI, MD, NJ, NY-CHIP, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.01.2023
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care, Hawaii UnitedHealthcare Community Plan QUEST Integration Program, Maryland HealthChoice, New Jersey FamilyCare, New Jersey Managed Long Term Services and Supports (MLTSS) Pharmacy Program, New York Child Health Plus, New York Essential Plan, Pennsylvania UnitedHealthcare Community Plan for Kids, Rhode Island Children with Special Health Care Needs, Rhode Island UnitedHealthcare RIte Care, Rhode Island UnitedHealthcare Rhody Health Partners, Rhode Island UnitedHealthcare Rhody Health Partners ACA Adult Expansion
GLP-1 Agonists (Arizona) Prior Authorization Form - Community Plan
Last Published 11.01.2023
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care
Medicaid Synagis Authorization Request Form - Community Plan
Last Published 04.01.2023
Please complete this entire form for UnitedHealthcare Community Plan members needing a Synagis prescription and fax it to the UnitedHealthcare Community Plan Prior Authorization Department. Excludes: New York Community Plan MLTSS, New York UnitedHealthcare Community Plan, New York UnitedHealthcare Wellness4Me
Opioid Products (Arizona) Prior Authorization Form - Community Plan
Last Published 01.06.2023
Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care