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1. Select Prior Authorization

To find the prior authorization request:

• Select Pharmacy network, the prior authorization.
• If you request financial assistance regularly it will appear on the homepage.

2. Complete the Form

The minimum information we need is:

• Patient name
• Method to contact the patient (e.g. phone number or email)
• Prescriber

3. Send Prescription and Add Documentation

Don't forget to send the prescription to the pharmacy selected! At this point you will be able to answer the questions or provide other forms of documentation.