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Prior Authorization Forms
UNI-MDP-MDM- Prior Authorization Forms - Information for Prescription Drugs
Prior Authorization and Exception Request Forms:
- General Exception Request Form (Self Administered Drugs)Open a PDF - (used for requests that do not have a specific form above, or may be used to request an exception)
- Quantity Limit Exception FormOpen a PDF
- Medicare D End Stage Renal Disease - Request for Drug EvaluationOpen a PDF
- Medicare D Hospice - Request for Drug EvaluationOpen a PDF
- Medicare D Lidocaine Patch & Flector Patch - Request for Drug EvaluationOpen a PDF
- Medicare D Opioid Prior Authorization Form - Request for Drug & Morphine Milligram Equivalents ReviewOpen a PDF
- Medicare D Sulfonylurea - Request for Drug EvaluationOpen a PDF
Univera Healthcare contracts with the Federal Government and is an HMO plan with a Medicare contract. Enrollment in Univera Healthcare depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_5996_C.
This page last updated 10-01-2019.