Below is a list of forms used in day-to-day interactions with our Plan. Visit this section regularly to ensure you have the latest copy. Provider Forms 2020 2021 20202020 Member Transfer Request Prior Auth. / Drug Exception Request Form Health Assessment Tool 2020Part B Injectable Prior Authorization List 2020Specialty Medication Form 2020UM Referral Form 2020Pre-Certification Request Form 2020 DEA Protocol FormProvider Grievance Form 20212021 Member Transfer Request Prior Auth. / Drug Exception Request Form Health Assessment Tool 2021Part B Injectable Prior Authorization List 2021 Specialty Medication Form 2021UM Referral Form 2021Pre-Certification Request Form 2021 DEA Protocol FormProvider Grievance Form
