Submit a prior authorization (PA), appeal, or exception request online by using our online 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 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 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.
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 MeridianRx can reach the contact person
Email Address - Submitter’s email address
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