Rhode Island Community Plan Pharmacy Prior Authorization Forms
To simplify your experience with prior authorization and save time, please submit your prior authorization request through the following online portals:

Electronic Prior Authorization (ePA)
Submit an ePA using CoverMyMeds

Electronic prior authorization (ePA)
Submit an ePA using SureScripts
Otherwise, you can submit requests by completing and faxing the applicable form below. You can search for a drug specific form by entering the requested drug in the search box below. If your search does not yield a result, please use this Prior Authorization Request form.
-
ADHD Products (HI, NJ, NY-CHIP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.01.2023
-
Antipsychotics (Rhode Island) Prior Authorization Form - Community Plan
Last Published 02.24.2022
-
Cough and Cold, Opiate Combination (Rhode Island) Prior Authorization Form - Community Plan
Last Published 02.24.2022
-
Dry Eye Disease (Rhode Island) Prior Authorization Form - Community Plan
Last Published 02.24.2022
-
Dupixent (AZ, HI, MD, NJ, NY-CHIP, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan
Last Published 04.01.2023
-
GLP-1 Agonists (Rhode Island) Prior Authorization Form - Community Plan
Last Published 02.24.2022
-
Hepatitis C Medications (Rhode Island) Prior Authorization Form - Community Plan
Last Published 02.24.2022
-
Medicaid Synagis Authorization Request Form - Community Plan
Last Published 04.01.2023
-
Opioid Products (Rhode Island) Prior Authorization Form - Community Plan
Last Published 02.24.2022
-
SGLT-2 Inhibitors (Rhode Island) Prior Authorization Form - Community Plan
Last Published 02.24.2022
-
Suboxone / Subutex (Rhode Island) Prior Authorization Form - Community Plan
Last Published 02.24.2022