This pre-authorization form allows members to initiate a request for a non-formulary medication.

The pharmacy department will review your request and process. The prescribing physician must sign and clearly print his/her name.

The following criteria will be used when reviewing a request:
   *The member has failed a trial of preferred and standard medications.
These medications should include:
   -Drugs in the same therapeutic class as the requested drug
   -Other recognized drug therapies for the medical condition
   *Drugs on the preferred and standard list are contraindicated for this member.

* Indicates Required Fields

Patient Name: *
Member Number: *
Drug and Dose: *
Anticipated Length of Therapy: *
Reason For Request: *
Diagnosis: *
Therapies Tried: *
Physician Name: *
Physician Phone:
Physician Fax:

Pharmacy Prior Authorization Request