Magellan Rx Provider Forms

Home Delivery Provider Order Form

Home Delivery Provider Order Form (Arizona Only)

Independent Pharmacy Recredentialing Form

Prescription Drug Appeal Form – Evry Health

Prescription Drug Independent Review Organization Form – Evry Health

Prescription Drug Prior Authorization Form – Buprenorphine

Prescription Drug Prior Authorization Form – Dry Eye Agents

Prescription Drug Prior Authorization Form – Dupixent

Prescription Drug Prior Authorization Form – Evry Health

Prescription Drug Prior Authorization Form – General

Prescription Drug Prior Authorization Form – Growth Hormone

Prescription Drug Prior Authorization Form – Hepatitis C

Prescription Drug Prior Authorization Form – Hypoglycemics

Prescription Drug Prior Authorization Form – Immunomodulators

Prescription Drug Prior Authorization Form – Migraine

Prescription Drug Prior Authorization Form – Narcotics (Long Acting)

Prescription Drug Prior Authorization Form – Narcotics (Short Acting)

Prescription Drug Prior Authorization Form – Praluent/Repatha

Prescription Drug Prior Authorization Form – Precision Formulary

Prescription Drug Prior Authorization Form – SFHP

Prescription Drug Prior Authorization Form – Synagis

Prescription Drug Prior Authorization Form – Xolair

Provider Disclosure Form

Specialty Pharmacy – Patient Enrollment Form

Specialty Pharmacy – Patient Enrollment Form (Arizona Only)

Specialty Pharmacy – Provider Order Form

Specialty Pharmacy – Provider Order Form (Arizona Only)

Specialty Pharmacy – Sublocade Order Form