Submit a prior authorization (PA), appeal, or exception request online by using our online form.
Prescribers Web Prior Authorization User Guide
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