If Pharmacy Benefits Program (BPB) Service Providers have questions please contact a PBP services representative at (202) 671-4815.

PBP Service Provider Information

• PBP Provider Manual HIV/AIDS and Other Specialty Care Services
• PBP Drug Formulary
• PrEP Education for Healthcare Professionals

PBP Provider Forms:

• Prior Authorization Forms:
  • Daklinza
  • Daliresp; Initial Form
  • Daliresp; Renewal Form
  • Harvoni
  • Lamivudine and Tenofovir
  • Mavyret
  • Sovaldi
  • Viekira
  • Zepatier
  • Hepatitis C Beneficiary Disclosure & Commitment Form
     
• Other Prior Authorization Forms:
  • Daraprim
  • Dronabinol
  • Dronabinol Informed Consent Form
  • Epogen, Procrit
  • Invirase
  • Subutex, Suboxone
  • Serostim
  • Early Refill Extended Supply Request [PDF]
  • Third Party Liability Form [PDF]
  • Early Medical Supply Physician's Form

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