• DME Precertification Additional Code Form
• DME Precertification Form
• DME Authorization Change Form
• DME Re-Certification Form
• Erythropoietin Stimulating Agents (ESA) Request Form
• Formulary Exception/Prior Authorization Request Form
• Fourth Tier Drug List
• Geisinger Gold and Medicare Vaccine Coverage
• Geisinger Gold Nonpar Provider Appeal Process Form
• Geisinger Gold Well Visit Incentive Form
• Hepatitis C Virus Direct-Acting Antivirals Prior Authorization Request Form
• Home Health Precertification Form
• Inpatient Admission Review Form
• Inpatient Planned Procedure Precertification Form
• Inpatient Rehabilitation Precertification Form
• Inpatient Update Review Form
• LA Atypical Antipsychotic Request Form
• Medical Benefit Outpatient Drug Authorization Form
• Newborn Information Form
• NOMNC-Sample Instructions
• Non-Emergent Transport Form
• Opioid Cumulative Morphine Equivalent Dose (MED) Prior Authorization Form - For Medicare
• Opioid Use Prior Auth Form
• Organizational Determination Form
• Outpatient Radiology Notification List
• Outpatient Radiology Prior Authorization Form
• Outpatient Rehabilitation Therapy Services Request Form
• Outpatient Prior Authorization Form
• Prior Authorization List
• SNF Concurrent Review Form
• SNF Discharge Planning Notification Form
• SNF Precertification Form
• Subutex®/Suboxone® Prior Authorization Request Form
• ≤ 17 Years Old Antipsychotic Authorization Request Form
  
  

Specialty vendor drug program

• Specialty Vendor Drug List
• Specialty Referral Form – Download and complete the MedImpact Direct Specialty® referral form
• Specialty Drug and Pharmacy List – GHP Family