Prior Authorization Forms

When completing rosiglitazone (Avandia™) access forms, fill out section 2 of the application completely if your patient is an existing ADAP client who is newly initiating rosiglitazone or is an ADAP client who previously received rosiglitazone through another payer (i.e. Medi-Cal, Medicare Part D or Private Payer). Fill out section 3 of the application completely if your patient is currently taking rosiglitazone or continuing treatment. Download a copy of the access form and submit the form prior to dispensing rosiglitazone. Please be sure to include all requested clinical information including a signed informed consent form and a list of therapies that have been tried and failed.
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