Medication Prior Authorization Form

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