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Prior Authorization

There are two ways a request can be created:

Select his option if you would like help with:

• Prior Authorization
• Appeals
• Drug Specific Form - These forms will ask you a few questions about the drug. Completion of this form makes it more likely your request will be reviewed accurately and quickly. It is highly recommended to complete this form where available.
• General Form - Can be used for any drug, but does not ask any drug specific questions.

Financial Assistance

Each form will require some basic information (patient name, DOB, prescriber, pharmacy). 

• Drug Specific Form - Medical records are not required, but highly recommended to be submitted with the request.
• General Form - Some type of documentation will be required with the request.