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DOCUMENTS & FORMS

Everything you need in one place

Here are some of the common documents and forms you may need in order to treat our members and do business with us.

Manuals, Policies & Guidelines

PDF iconProvider Administration Manual (PAM)

Clinical Practice Guidelines

Authorizations & Appeals

PDF iconPredetermination Authorization Request

PDF iconDurable Medical Equipment (DME) Authorization Request

PDF iconInpatient/Outpatient Services Authorization Request

PDF iconProvider Appeal Form

PDF iconProvider Reconsideration Form

Pharmacies & Prescriptions

PDF icon2022 Prescription Drug List (Formulary)

PDF iconProvider-Administered Specialty Pharmacy Products

PDF icon2022 Part D Prior Authorization Criteria

PDF iconStep Therapy Guide

Network Participation

PDF iconProvider Data Change Form

Quality Care Initiatives

PDF iconProvider Reimbursement Quick Reference Guide

PDF iconQuality Program Information

PDF iconDiabetes Prevention Program (DPP) Referral Form
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