PCA Rx

To submit a prior authorization online, please click the button below to use the web form.

Diabetic Glucagon-like peptide agonists (GLP-1) (Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza)

  • Note: This is a closed formulary. Do not submit requests for NON-FORMULARY Adlyxin, Bydureon or Byetta. Non-formulary drugs are not subject to prior authorization review. Please submit questions to info@pcarx.com or fax to 210-624-8896.

Weight Loss Agents (generic stimulants, Qysmia, Saxenda, Wegovy)

  • Note: This is a closed formulary. Do not submit requests for NON-FORMULARY Contrave or Xenical. Non-formulary drugs are not subject to prior authorization review. Please submit questions to info@pcarx.com or fax to 210-624-8896.

PDF forms are available below to submit a prior authorization through fax.

Title
90degrees, affirmedrx, BCBSAL, BCBSFL, BCBSMN, Credence, HiLab, oreadrx, pcarx, rxsense, verusrx August 31, 2023
pcarx December 30, 2022