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_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_Diabetic GLP-1 Agonists PA Form | Mounjaro, Ozempic, Rybelsus |
| UNC Health PPI PA Form | Dexlansoprazole, Esomeprazole, Omeprazole, Pantoprazole |
| UNC Health_Xolair_PA Form | Xolair |
| UNC Health_Weight Management Agents (Foundayo, Wegovy, Zepbound) PA Form | Foundayo, Wegovy, Zepbound |
| Title | Categories | Update Date | Download |
|---|---|---|---|
|
FDA Medwatch Form 1 4113 downloads |
aboundrx, affirmedrx, capslrx, Four Corners Health, HiLab, IH-Script, inscript, oreadrx, pcarx, rxsense, UNC Health, verusrx | March 31, 2026 | Download |
For all other prior authorization please click the button below to submit using the web form.