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Pharmacy Forms and
Prior Authorization Information

Prior Authorization Form

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. Please fill out this form completely, including signature, and fax to CVS at the appropriate fax number.

Prior Authorization Form (PDF)

Specialty Prior Authorization Forms

Specialty Prior Authorization Form (PDF)

Hepatitis C Medications Prior Authorization Form (PDF)

Synagis Prior Authorization Form (PDF)

Prior Authorization Guidelines

Prior Authorization Guidelines (PDF)