A Drug Prior Authorization Request Form needs to be completed by the healthcare provider and submitted as directed.


  • PD1 / PDL1 Inhibitors
    • Atezolizumab ( Tecentriq)
    • Avelumab (Bavencio)
    • Durvalumab ( Imfinzi)
    • NiIvolumab (Opdivo)
    • Pembrolizumab (Keytruda)

This health plan is underwritten by Gundersen Health Plan, Inc.