To submit a prior authorization online, please click the button below to use the web form.
PDF forms are available below to submit a prior authorization through fax.
| 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_Infertility PA Form | Cetrotide, Follistim AQ, Gonal-F, Leuprolide, Menopur, Novarel, Ovidrel, Pregnyl |
| UNC Health_Oncology PA Form | |
| UNC Health_PCSK9 PA Form | Praluent, Repatha |
| UNC Health PPI PA Form | Dexlansoprazole, Esomeprazole, Omeprazole, Pantoprazole |
| UNC Health_Xolair_PA Form | Xolair |
| UNC Health_Wegovy & Zepbound PA Form | Wegovy, Zepbound |
| UNC Health_Standard-Prior-Authorization-Request-Form | All other medications not listed above |
| Title | Categories | Update Date | Download |
|---|---|---|---|
|
FDA Medwatch Form 1 3235 downloads |
affirmedrx, Four Corners Health, HiLab, inscript, oreadrx, pcarx, rxsense, UNC Health, verusrx, wellyfe | December 23, 2025 | Download |