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)