Prescribers

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

Prescriber Web Prior Authorization

Date Of Request *

* Indicates required field

Patient Information

As of April 1st, 2022, Michigan and Illinois Medicaid prior authorizations will be submitted via Cover My Meds

Member ID *

First Name *

Last Name *

Plan Name

Date of Birth *

Gender *

Prescriber Information

Prescriber Name

Prescriber NPI # *

Prescriber Phone *

Prescriber Fax *

Prescriber Contact Person *

Service Type

Pharmacy / Retail

Home Infusion / TPN / Enteral

Pharmacy Name

Pharmacy NCPDP:

Pharmacy Fax Number

Diagnosis and Medical Information

If requesting a compound, please enter for “Compound Bucket” and outline the ingredients in the additional information field.

Medication *

Urgency *

Expected Length of Therapy *

Diagnosis *

Frequency *

Quantity *

Pending Discharge *

Day Supply *

Drug Allergies *

Yes No

Trial & Failure *

Yes No

Vacation Fill

Early Refill

Additional 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.