UNC Health

PDF forms are available below to submit a prior authorization through fax. For Foundayo, Wegovy, and Zepbound requests, please use downloadable form below. 

Name Of PDFs Category
UNC Health_Dupixent_PA Form Dupixent
UNC Health_Diabetic GLP-1 Agonists Form Ozempic, Mounjaro, Trulicity, Liraglutide, Rybelsus
UNC Health_Androgens & Anabolic PA Form Jatnzo, Testim, Testoerone, Xyosted
UNC Health_Oral CGRP PA Form Nurtec ODT, Qulipta, Ubrelvy
UNC Health_CGM PA Form Dexcom, FreeStyle Libre
UNC Health_PPI PA Form Dexlansoprazole, Esomeprazole, Omeprazole, Pantoprazole
UNC Health_Request_Reviewer_Fax Form Request to speak to reviewer
UNC Health_Xolair_PA Form Xolair
UNC Health_Weight Management Agents (Foundayo, Wegovy, Zepbound) PA Form Foundayo, Wegovy, Zepbound

 

For all other prior authorization please click the button below to submit using the web form.