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Nebraska 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

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Electronic prior authorization (ePA)

Submit an ePA using SureScripts

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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.