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Prior Authorization

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

  • Prior Authorization
  • Appeals
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urlhttps://www.youtube.com/watch?v=BbPvbacH5Ms


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.

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    urlhttps://www.youtube.com/watch?v=YHPlEpoz08E