Prior Authorization

Member Information

Member ID

PCN (if known)

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Gender


Drug Information

Label Name

Drug Info


Requestor Information

Requestor Name

Phone

Fax

Email

Relationship to Member **

**If the requestor is not the Member or a Prescriber, attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent. We also accept copies of legal documents recognized by the state or other legal documentation showing authority). For more information on appointing a representative, you may contact your plan.

Reason

(Please include the prescriber's/doctor's first name, last name, and phone number, along with the reason)

Optional: Attach Supporting Documentation

If you have any documentation to support the prior authorization request, attach those documents here (PDFs only).


File Upload (doc, docx, pdf, txt)


Submit a prior authorization (PA), appeal, or exception request online by using our online form.

Download Prior Authorization Form

This web form is used to submit a prior authorization request for a drug. The request may be submitted by the member or his or her doctor or pharmacy. All fields marked with a red asterisk (*) are required fields.

MEMBER INFORMATION

  • Member ID – Enter your Member ID # (found on your Membership Card)
  • PCN – Enter your Processor Control Number (PCN) which is found on your Membership Card under RxPCN
  • First Name – Enter your first name as printed on Membership Card
  • Last Name – Enter your last name as printed on Membership Card
  • Date of Birth – Enter your date of birth in the format MM/DD/YYYY (e.g. 01/20/1959)
  • Gender – Select your gender

DRUG INFORMATION

  • Drug Info - Type in the name of the drug for which the prior auth request is being created. The system will search for drugs that match what is being typed in. Once the drug you are searching for appears in the drop-down menu, left click on the drug and the system will populate info about the drug.
  • Number of Refills Requested
  • Prior Therapy - Details including Date Ranges, Medications, Patient Reaction, Results of Therapy, and any additional information.

REQUESTOR INFORMATION

  • The Requestor Information section is where info about the person submitting the request should be entered.
    • Requestor Name - Name of person submitting prior auth request
    • Phone Number – Phone number where Appro-Rx can reach the contact person
    • Email Address - Submitter’s email address
    • Fax Number - Submitter's fax number
    • Relationship to Member – Enter your relationship to the member
    • Reason – This box is an optional field. Enter a brief description of the reason for the prior auth