Pharmacy prior authorization

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


Below is the prior authorization request form to be used. Please remember that older versions of this form will not be accepted. Be sure to fax pharmacy prior authorization to 1-858-357-2534 or submit to your plan medical group.



Fill out a prior authorization form

Please complete the prescription prior authorization form and fax it to us at 1‑858-357-2534. 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.

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?