Forms & publications

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Exondys 51 request form

Use this form to request prior authorization to prescribe Exondys 51 (eteplirsen).
  • 13-0012
  • Form
Alternate language versions:

Expedited prior authorization (EPA) inventory

This guide provides an inventory of expedited prior authorization (EPA) criteria by code(s). Use this guide to determine the appropriate EPA number when submitting your claims.
  • Publication

IV Iron request form

Use this form to request prior authorization for prescribing IV Iron.
  • 13-0013
  • Form
Alternate language versions:

Nucala request form

Use this form to request prior authorization for prescribing Nucala (mepolizumab SC injection).
  • 13-0011
  • Form
Alternate language versions:

Opdivo request form

Use this form to request prior authorization for prescribing Opdivo.
  • 13-0010
  • Form
Alternate language versions: