Prior Authorization/Medical Exception Forms

Click below to access the PA/medical exception forms for these popular pharmacy benefit managers (PBMs) and healthcare plans.*

Commercial Forms
Medicare Forms
*Medicare prescription drug plans (Part C and Part D) are required to accept the CMS standard PA form; however, the companies listed above have their own PA forms that can be downloaded to support medical exception requests.
Prior Authorization Forms

Call the Provider Services number on your patient’s healthcare plan or PBM card to verify if Prior Authorization (PA) is required for the medication your patient needs. If so, complete and submit the latest version of their PA form, which is usually found on the plan or PBM website. Examples of four PA forms are provided below for reference.

Blue Cross
Blue Shield
North Carolina
Download
Horizon
Blue Cross
Blue Shield
Download
Sentara
Health Plans
Download
University of Utah Health Plans
Download
Parkinson’s Disease patients discussing treatment options
Medicare Part D: Extra Help Program

Learn how the Extra Help program enhances Medicare Part D benefits for your eligible patients living with Parkinson’s in 2025—enabling them to fully leverage their plan for optimal care and support.

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Additional Resources
Find additional resources to help your patients living with Parkinson’s access helpful educational materials, receive the support they need, or connect with local communities.
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