Get Benecard Prior Authorization Form

Completing the Benecard Prior Authorization Form online is an essential step in managing your prescriptions effectively. This guide provides clear instructions to help you navigate the form with ease, ensuring a smooth online submission process.

Follow the steps to complete the form successfully.

1. Press the 'Get Form' button to obtain the Benecard Prior Authorization Form and open it in the editor.
2. Begin by filling out the patient information section. Include the cardholder ID number, Rx group number, and the cardholder's full name. Ensure accuracy, as this information is critical for processing.
3. Indicate whether the address change is temporary or permanent. If it is a permanent change, it is advised to contact your plan administrator for updated records.
4. Enter the shipping address, including city, state, and zip code. Be sure to provide a daytime and evening phone number, as well as a cell phone number if available.
5. Fill in the email address for notifications and updates regarding your prescription order.
6. For each person submitting prescriptions, complete the relevant fields with the patient’s name, date of birth, gender, and prescriber information. List any allergies or health conditions, and specify the relationship to the cardholder.
7. Indicate if you prefer easy-open caps for the medications and whether you permit substitutions for lower-cost or generic medications.
8. If you are submitting multiple prescriptions, ensure that each patient's information is clearly listed along with their respective Rx numbers and medications.
9. In the payment information section, select your payment method and provide relevant details. If paying by credit card, include the card number, expiration date, and the signature of the cardholder.
10. Review all entries for accuracy before submission. Once all details are correct, you can save the changes, download, print, or share the filled-out form as needed.

Begin completing your Benecard Prior Authorization Form online today for a seamless prescription process.