| Assigned number | Title | Release date Sort ascending | Language | Available to order |
|---|---|---|---|---|
| F-11075A | Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, Instructions (PDF) | 07/01/2023 | English | No |
| F-11075 | Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request (PDF) | 07/01/2023 | English | No |
| F-11075 | Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request (Word) | 07/01/2023 | English | No |
Last revised June 27, 2026