Providers_forms_PA

A Prior authorization form needs to be completed by the healthcare provider and directed, by fax or mail, to Gundersen Health Plan Pharmacy Management. Click here to access the form.


     
    • PD1 / PDL1 Inhibitors
      • Atezolizumab (Tecentriq®)
      • Avelumab (Bavencio®)
      • Durvalumab (Imfinzi®)
      • NiIvolumab (Opdivo®)
      • Pembrolizumab (Keytruda®)