Prior Authorization Forms
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)
- 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
Univera Healthcare is an HMO plan and PPO 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_8829_C.
This page last updated 10-01-2022.