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Senior Preferred Forms

Prior Authorization Forms 

Gundersen Health Plan utilizes and adopts nationally developed medical policies; commercially recognized criteria sets; regionally developed medical coverage policies; and locally produced specialty medical coverage policies. Additionally, the Health Plan involves appropriate practitioners in development, adoption and review of criteria and medical coverage policies. All criteria are available upon request by contacting the Health Plan Medical Management Department. A written copy can be sent electronically, by mail, or directly communicated via the telephone.

Commercial Prior Authorization

Pharmacy Forms for Healthcare Providers

If you have questions about the drug prior authorization process, please review the provider manual, or the drug prior authorization process overview.

Provider Change Notification Form

Please use this form to notify Gundersen Health Plan of any changes, additions or terminations within your facility.

Provider Participation Request Form

MyPlanTools Access Request Form

Electronic Data Interchange (EDI)