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  • () Prior Authorization Request Form To Be Completed And Signed By The Prescriber

Get () Prior Authorization Request Form To Be Completed And Signed By The Prescriber

() Prior Authorization Request Form To be completed and signed by the prescriber. To be used only for prescriptions which are to be filled through the Department of Defense (DoD).

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The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider. As mentioned in the “How does prior authorization work?” section above, this will then often prompt a time-consuming back and forth between the provider and payer.

Please call us at 800.753. 2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.

Prior authorization ensures that you get the prescription drug that is right for you and that is covered by your benefit. If it's determined that your plan doesn't cover the drug you were prescribed, you can ask your doctor about getting another prescription that is covered. You'll receive it for your plan's copayment.

Express Scripts' prior authorization phone lines are open 24 hours a day, seven days a week, so a determination can be made right away. If the information provided meets your plan's requirements, you pay the plan's copayment at the pharmacy.

If your prescription requires prior authorization, you or your doctor can initiate the prior authorization review by calling Express Scripts at 1-800-753-2851.

For urgent or expedited requests please call 1-855-297-2870. This form may be used for non-urgent requests and faxed to 1-844-403-1029. OptumRx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations.

Please call us at 800.753. 2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232