Prior Authorization

There are two ways a request can be created:

Select his option if you would like to create a request for:

• Prior Authorization
• AppealsDrug 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.

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.

Request that we look into reducing a copay on a medication for a patient.