Fill out a prior authorization form
Please complete the prescription prior authorization form and fax it to 1-888-836-0730 for Commercial and CalChoice members, or 1-855-245-2134 for Covered California™ members. 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 provide, the better we can fulfill your request.
Have a question?
Call 1-800-359-2002 between 8 am and 6 pm, 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