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 Pharmacy Forms and Prior Authorization

 

ePharm Prior Authorization

Prior Authorization Forms - Drug-Specific (THESE FORMS ARE HOSTED ON MEDMETRICS SITE)

Prior Authorization Form - Generic

This form is to be used by participating providers to request coverage for medications requiring prior authorization other than medications which are part of NHP's Specialty Pharmacy or Step Therapy program. Please fill out this form completely, including signature, and fax to MedMetrics Health Partners at 1-800-918-7542.

Specialty Order Forms

Ordering instructions are included with forms.