Common Carrier Ride Request Form

Special Transportation Ride Request Form - Care Coordinator

Common Carrier Ride Request Form - Care Coordinator

Samsca® (tolvaptan) - Medicaid

Prior Authorization, Quantity Limit

Hypoactive Sexual Desire Disorder (HSDD) - Commercial - Effective Date 03/01/2025

Prior Authorization, Quantity Limit

Hyperhidrosis - Commercial - Effective Date 03/01/2025

Prior Authorization, Quantity Limit

Fintepla® (fenfluramine) - Medicaid

Prior Authorization, Quantity Limit

P35-21 eviCore Healthcare Specialty Utilization Management (UM) Program – Medical Oncology Drug Prior Authorization Updates for Fully Insured Commercial and Medicare Advantage Subscribers

P33-21 Change to Medical Review Process for Outpatient Therapies Services

Zokinvy™ (lonafarnib) - Medicaid

Prior Authorization, Quantity Limit