Medication Prior Authorization Form
Hi!

We have received information from your pharmacy that your insurance is not covering your medication.


Can you please help us with the following questions to be able to submit the pre-authorization promptly and accurately. Please keep in mind that authorizations can be a lengthy process and generally take at least 72 hours to complete.

What is the patient's
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
Phone Number *
Your answer
DOB *
MM
/
DD
/
YYYY
Insurance information
Carrier name *
Your answer
Member ID *
Your answer
Plan Name *
Your answer
BIN # *
Your answer
PCN # *
Your answer
RxGroup *
Your answer
Medication information
Medication name *
Your answer
Dose *
Your answer
Instructions *
Your answer
What medications have you tried before? *
Your answer
How long were they tried? *
Your answer
What was the reason for discontinuation? *
Your answer
How long have you been on current medications? *
Your answer
Submit
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