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 | Categories | Update Date | Download |
|---|---|---|---|
|
FDA Medwatch Form 1 2711 downloads |
90degrees, affirmedrx, BCBSAL, BCBSFL, BCBSMN, Credence, Four Corners Health, HiLab, inscript, oreadrx, pcarx, rxsense, verusrx | February 26, 2025 | Download |
|
PCA Rx Prior Authorization Request Form 1 2213 downloads |
pcarx | December 30, 2022 | Download |