Virginia 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:

Electronic Prior Authorization (ePA)
Submit an ePA using CoverMyMeds

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.
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Anti-allergens, Oral (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Anti-allergens, Oral - Palforzia (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Antiemetic/Antivertigo Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Antifungals, Oral (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Antifungals, Topical (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Antimigraine Agents, Others (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Antimigraine Agents, Vyepti (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Antipsychotics in Children Younger Than 18 Years Old (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Briumvi (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Cinqair (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Colony Stimulating Factors, Non-Preferred (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Cytokine and CAM Antagonists and Related Agents (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Duchenne Muscular Dystrophy (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Dupixent (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Fasenra (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Forteo, Tymlos, Teriparatide (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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GI Motility, Chronic (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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GLP-1 Receptor Agonists for Cardiovascular Risk Reduction (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Growth Hormone (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Hepatitis C Antivirals, Non-Preferred (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Hereditary Angioedema (HAE) Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Incretin Mimetics, Non-Preferred (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Juxtapid (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Lipotropics, Other (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Multiple Sclerosis (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Narcolepsy Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Nucala (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Ocrevus (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Oral Buprenorphine Products (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Proton Pump Inhibitors (PPIs) (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Short and Long-acting Opioids (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Sickle Cell Disease Medications (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Stimulants/ADHD Medications for Children Less than FDA Indicated Age and Adults (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Tezspire (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Tysabri (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Weight-Loss Management (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025
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Xolair (Virginia) Prior Authorization Form - Community Plan
Last Published 05.30.2025