To submit a prior authorization online, please click the button below to use the web form.
Formulary Glucagon-Like Peptide-1 (GLP-1) Agonists are listed below. This is a closed formulary. Non-formulary drugs are not subject to prior authorization review. Please submit questions to info@pcarx.com or fax to 210-624-8896.
For Diabetes: Exenatide, Liraglutide, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza
For Weight Loss: Liraglutide, Wegovy, Zepbound
PDF forms are available below to submit a prior authorization through fax.
| Title | Categories | Update Date | Download |
|---|---|---|---|
|
FDA Medwatch Form 1 3244 downloads |
aboundrx, affirmedrx, capslrx, Four Corners Health, HiLab, IH-Script, inscript, oreadrx, pcarx, rxsense, UNC Health, verusrx, wellyfe | December 30, 2025 | Download |