Forms & Brochures

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Pharmacy, Physician Certification Statement (PCS) Forms and Prior Authorization Forms

Commercial, CalViva Health & Medi-Cal Plans

• Pharmacy Prior Authorization Form – English (PDF)
• Commercial Inpatient Prior Authorization – English (PDF)
• Commercial Outpatient Prior Authorization – English (PDF)
• Medi-Cal CalViva Inpatient Prior Authorization Form – English (PDF)
• Medi-Cal CalViva Outpatient Prior Authorization Form – English (PDF)
• PCS Form – Request for Transportation – Medi-Cal – English (PDF)
• PCS Form – Request for Transportation – CalViva Health – English (PDF)
• PCS Form – Request for Transportation – CHPIV – English (PDF)

Ambetter

• Non-Formulary and Step Therapy Exception Request Form – English (PDF)

HMO, Medicare Advantage, POS, PPO, EPO, Flex Net, Cal MediConnect

• Medical Prior Authorization Form – English (PDF)

Medicare & Cal MediConnect Plans

• Medicare Outpatient Prior Authorization Form – English (PDF)
• Medicare Inpatient Prior Authorization Form – English (PDF)
• Cal MediConnect Prior Authorization Form – English (PDF)
• Medicare Hospice Form – English (PDF)

Covered DME and Home Respiratory Services

• Apria Covered DME and Home Respiratory Services – English (PDF)