Prior Authorization Request Form

For assistance please call (800) 588-6767
  • Drug Information

    Drug Search

    Enter values for one or more of the below drug search fields.
    Label Name:  
    NDC:  
    GPI 14:
    DDID:
        

  • Member Information

    Member Information

    Cardholder ID:  
    First Name:   Last Name:  
    Date of Birth:
    RadDatePicker
    RadDatePicker
    Open the calendar popup.
         
    Gender:  
    Phone Number:
    Address 1:   Address 2:
    City:   State:   Zip Code:  
       

  • Provider Information

    Provider Information

    Remember Me:  
    First Name:   Last Name:   NPI:    
    Specialty:
    Practice Name:
    Address 1:   Address 2:
    City:   State:   Zip Code:  
    Contact Person: Office Phone:   Office Fax:  

    Pharmacy Information

    Pharmacy Fax Number: Pharmacy Name:

    Medical Information

    Height:  ft  in Weight:  kgs  
    Drug Allergies: ICD Code:  
    Diagnosis:    
    Rationale for Request:    
       


  • Attachments

    Attachments

    Attachments are optional. If needed you can upload and attach files to this request.
    The following file extensions are allowed: ".pdf, .doc, .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.
      
        

 
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