Prior Authorization Form

SUBMIT A PRIOR AUTHORIZATION, APPEAL, OR EXCEPTION REQUEST ONLINE

There are three ways to submit a prior authorization:

1. Download the prior authorization form and submit with chart notes on this site.
2. Fax the prior authorization form to 513-897-1022 securely.
3. Call and request a form to be faxed or emailed at 513-879-1476.

For high likelyhood of approval:

• Chart Notes and Laboratory Results from Physician Required for Drug Evaluation
  • Failure to provide proof of labs/diagnostic criteria via chart notes may result in automatic denial.
  • Please include relevant labs, diagnostic tests, and or safety provisions used to determine appropriateness of
    medication (e.g. A1c, DEXA scan results, TB tests, Testosterone levels, PSA, Migraine frequency, etc.):

Please allow 2-3 business days for the prior authorization to be completed.