Prior Authorization Request Form

For assistance please call (800)-588-6767

Drug Search

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

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

Medical Information

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

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.

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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