Prior Authorization Web Form

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Request Information
Note: The prescriber attests that applying the standard turnaround time could seriously jeopardize the life, health, or safety of the member or others, due to the member’s psychological state, or in the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.
Patient Information
Format: 5 digits

Format: mm/dd/yyyy

Insurance Information
Prescriber Information

Medication/Medical and Dispensing Information
Partial matches are allowed, starting with the beginning of the medication's name. (minimum of 3 characters required)

Note: If not checked, the request will be reviewed as "Generic Substitution Permitted"
Date format: mm/dd/yyyy

Administration Location

If Yes, complete the three fields below.


Clinical Information Please provide all relevant clinical information to support a prior authorization review.

Additional Attachments PDF files only. Maximum of 50 pages per attachment. Larger documents should be faxed to (888) 346-0090.
I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, Insurer, Medical Group, or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.
Format: mm/dd/yyyy

Confidentiality Notice: The documents accompanying this submission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please arrange for the return or destruction of these documents immediately.