Pharmacy Prior Authorization Forms

To submit a request for pharmacy prior authorization, please fax the completed prescription drug prior authorization or step therapy exception request form to 1-844-823-5478 and include all documentation to support the medical necessity review. You can also submit your request over the phone by calling 1-855-772-9076.

Prescription Drug Prior Authorization or Step Therapy Exception Request Form

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591

PCN: ADV

Group: RX8808