Prior Authorization Request Form

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Drug Search

Enter values for one or more of the below drug search fields.

Label Name:	Enter 3 - 30 characters.
NDC:
GPI 14:
DDID:

Member Information

Cardholder ID:

First Name:

Last Name:

Date of Birth:

Gender:

Phone Number:

Address 1:

Address 2:

City:

State:

Zip Code:

Provider Information

Remember Me:
First Name:	Required	Last Name:	Required	NPI:	NPI must be 10 digits
Specialty:
Practice Name:
Address 1:	Required	Address 2:
City:	Required	State:	Required	Zip Code:	Required
Contact Person:		Office Phone:	Required Please specify a valid phone number	Office Fax:	Required Please specify a valid fax number

Medical Information

Height:	ft in	Weight:	kgs
Drug Allergies:		ICD Code:	Invalid ICD Code
Diagnosis:	Required 255 characters max
Rationale for Request:	800 characters max

Attachments

Attachments are optional. If needed you can upload and attach files to this request.
The following file extensions are allowed: ".pdf, .doc, .docx, .xls, .ppt, .txt"
Files must be 3 MB (3,000,000 bytes) or less.

Description of Attachment:
Select a file to upload:

	To attach a document you must click the 'Attach' button.

Submit for Processing

I confirm the information is correct and wish to submit the request. Required

Urgent requests should be reserved for those situations in which applying the standard timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function.

Member Validation

Description	What you entered	Eligibility File
Cardholder Id:
Member Last Name:
Member First Name:
Member DOB:
Member Gender:
Member Address 1:
Member Address 2:
Member City:
Member State:
Member Zip Code:
Member Phone Number:

Drug Information

Drug Name:

Therapeutic Class:

Strength:

Route:

Directions:

Quantity:

Days Supply:

Total # of Refills:

Member Information

Cardholder Id:

First Name:

Last Name:

Date of Birth:

Gender:

Phone Number:

Address 1:

Address 2:

City:

State:

Zip Code:

Provider Information

First Name:

Last Name:

Practice Name:

NPI:

Specialty:

Address 1:

Address 2:

City:

State:

Zip Code:

Office Phone:

Office Fax:

Contact Person:

Medical Information

Height:

ft in

Weight:

kgs

ICD Code:

Drug Allergies:

Diagnosis:

Rationale for Request:

Attachments


Please review request information. Select Confirm & Submit to complete submission, or Edit to return to the entry form.


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