- AARP / UnitedHealthcare Medicare Part D Coverage Determination Request Form (PDF - 32 KB)
- Community Care RX Request For Step Therapy Exception (PDF - 884 KB)
- Community Care RX Request For Quantity Limit Exception Form (PDF - 1.2 MB)
- Community Care RX Request For a Lower Co-Pay (Tiering Exception) Form (PDF - 677 KB)
- Community Care RX Criteria For VESIcare (PDF - 1.0 MB)
- Presbyterian Pharmacy Exception Review Request Form (PDF - 38 KB)
- Illinois Medicaid Prior Authorization Form (PDF - 812 KB)
- WellCare Medicare Coverage Determination Request Form (PDF - 412 KB)
- Model Coverage Determination Request Form (PDF - 312 KB)
Some forms and documents provided on this Web site are not the property of Astellas Pharma US, LLC, and may be subject to change.
