Prior Authorization Request Form

Prior Authorization Request Form
Under the terms of your prescription benefit plan, Prior Authorization is required for certain medications before your drug will be covered. Please consult the Prior Authorizations Medications List to determine if a prior authorization is required for a specific drug. If a prior authorization is required, your health care provider must submit this request form to Prescryptive for approval.

Please note:
1. All requests must include chart notes and supporting documentation.
2. Please indicate whether this request is Urgent at the bottom of the form. "Urgent" is defined as when the member or their provider believes that waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy.
Notifications

Approvals and denials will be provided by mail to the address on the request or, if no address is included, the physical address we have on file. Letters are sent to both requesting provider and member.

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Patient Information
Patient Name*

First NameMiddle NameLast Name
ID Number*
Date of Birth*

MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.
Prescriber Information
Prescriber Name*

First NameLast Name
Prescriber NPI*
Specialty
Prescriber Degree (Check one)*

MDDOARNPPA-C
Prescriber Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid fax number.
Contact Name
Date*

MonthDayYear
Date
Medication Information
Requested Medication*
Diagnosis*
Dose*
Frequency*
Quantity*
ICD 10*
Directions
Anticipated Duration

All medications tried for this diagnosis

	Medication/Dosage	Date(s) of Treatment	Outcome	Reason for Stopping
1
2
3
4
5

Medical Rationale*
Is this request urgent?

YesNo
*Urgent is defined as when the member or their provider believes that waiting for a decision under the standard time frame could place the member's life, health, or ability to regain maximum function in serious jeopardy.

Documentation (Chart Notes and supporting documentation required)
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Prior Authorization Request Form

Patient Information

Prescriber Information

Medication Information