Pharmacy General Medical Authorization eForm

Member Information
Enter Member Id and Date of Birth to validate Member before proceeding with the form.
Member ID*
Member DOB*
MM slash DD slash YYYY
Member Name*
First Last
Member LOB
Error Message
Member Phone Number*
Section 1: Provider Information
Provider Name*
First MI Last
Specialty
NPI (Type I)*
Contact Name*
First Last
Phone*
Fax*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Section 2: Servicing Facility Information
Servicing Facility Name*
NPI(Type II)*
Tax ID*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Extension
Different mailing address
- Is Mailing Address different than above?
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Section 3: Clinical Information
Requested J-Code*

Example J code: A1234
J-Code Response
J-Code Error Message
Drug name and strength
Units requested

Please enter a number from 0 to 9999999999.
Please see Prior Authorization Reference Guide to access our searchable tool for procedure/service codes (CPT codes) to determine if prior authorization is required.
Limit 5 CPT Codes
Requested CPT code(s)
(Click + or - at the right to add up to 5 CPT Codes)
Example CPT code: 12345
Dates of Service*
MM slash DD slash YYYY
Request type*
Request type *
- Initial
- Continuation
Directions*
ICD 10 Code(s)*
(Click + or - at the right to add up to 5 Diagnoses)
Example ICD 10 Diag Code: Z87.890
Section 4: Attachments
Clinical notes / labs / documentation*
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 10 MB.
Upload only PDF and Word files
MMP
- Standard - Defaulted
- Expedited - By checking Expedited, you are stating that processing this request in the standard time (72 hours) could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
All others
- Standard - Defaulted
- Expedited - By checking Expedited, you are stating that processing this request in the standard time (14 days) could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
Request Method*
Request Method *
- Standard
- Expedited
Signature*
Signature Date*
MM slash DD slash YYYY
Comments
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Member Information

Section 1: Provider Information

Section 2: Servicing Facility Information

Section 3: Clinical Information

Section 4: Attachments