On this page you will find links to the pharmacy forms that Gundersen Lutheran Health Plan providers request most often. If you have questions about this process, please review the provider manual, or the drug prior authorization process overview.

Forms for Healthcare Providers

• Employer Group (Commercial) Drug Prior Authorization
• Request for Medicare Prescription Drug Coverage Determination Form
• Pharmacy and Therapeutic Committee: Formulary Request for Review

Completed forms should be sent to:

Gundersen Lutheran Health Plan
Pharmacy Department NCA2-01
1836 South Avenue
La Crosse, WI 54601 or faxed to the number on the form

Forms for Network Pharmacies

• Request for Prescription Information or Change form  (This form is for network pharmacies to use to alert a healthcare provider of the need for a prior authorization. Please note, this form is not sent to the health plan, but rather the healthcare provider.)