Pharmacy prior authorization

Before you fill a new prescription, make sure your medication is covered.

Here's the form to use to request prior authorization. Please remember that older versions of this form will not be accepted. Be sure to send Pharmacy Benefit PA requests to the number below. Medical benefit requests can be sent to the number below or your plan medical group.


Fill out a prior authorization form

Complete the prescription prior authorization form and fax it to us at 858.357.2534. Be sure to include any type of support that may be important to review such as chart notes or lab data. The more information you can give us, the better we can fulfill your request.

Have a question?
Call 1.800.359.2002 between 8 a.m. and 6 p.m., Monday through Friday.

Download the form

Here are some things we'll need from you:

  • List of symptoms
  • Lab results with dates
  • Justification for initial/ongoing therapy or increased dosage
  • Notice of any drug, procedure or surgery that may harm the patient
  • Any additional information or comments that may be helpful such as drug list tier exceptions


Download the form

Looking for online forms to submit pharmacy prior authorization requests?

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