Please select Members or Prescribers to submit a prior authorization (PA), appeal, or exception request online using our online form.
Submit a prior authorization (PA), appeal, or exception request online by using our online form.
Web Prior Authorization User Guide
If you would like to check the status of your Prior Authorization with your authorization ID, please call 855-323-4580.
Diagnosis and Medical Information
Optional: Attach Supporting Documentation
You must include all necessary clinical documentation, office notes, and all related laboratory results to ensure a complete PA review. (PDFs only).
If your previous request was denied and you would like to submit an appeal check this box and enter "Appeal" in the Additional Information box above.
Preferred Pharmacy Search