Required on some medications before your drug will be covered. If your health plan's formulary guide indicates that you need a Prior Authorization for a specific drug, your physician must submit a prior authorization request form to the health plan for approval. If the request is not approved, please remember that you always have the option to purchase the medication at your own expense. To obtain the correct form, select the appropriate drug below and follow the instructions at the top of the form. You can search this page by using the search function within your application. (Press Ctrl+F on Windows or Command+F on Mac to bring up the search bar).
[No results found.] /content/myprime-v2/en/forms/coverage-determination /content/myprime-v2/en/forms/coverage-determination/prior-authorizationPrior Authorization © Prime Therapeutics LLC
Our purpose is to help people get the medicine they need to feel better and live well. Learn more at
PrimeTherapeutics.com
Our content providers have utilized reasonable care in collecting and reporting the information contained in the Products on this website and have obtained such information from sources believed to be reliable. However, the content providers do not warrant the accuracy of the information in the website, nor of codes, prices or other data available on this website. Information reflecting prices is not a quotation or offer to sell or purchase. The clinical information contained in the information is intended as a supplement to, and not a substitute for, the knowledge, expertise, skill, and judgment of physicians, pharmacists, or other healthcare professionals in patient care. The absence of a warning for a given drug or drug combination should not be construed to indicate that the drug or drug combination is safe, appropriate or effective in any given patient.
Last updated:© 2024 Prime Therapeutics LLC. All rights reserved.
System errorWe're sorry, but this service is not available at the moment
We cannot complete your request right now. Please click the "refresh" button in your browser/window, or try again soon. We apologize for the inconvenience.
Error identifier: [ERROR IDENTIFIER] Please verifyYou are requesting consent to view and manage this member’s prescription information on MyPrime. This consent will be in effect for one full year from the date it is granted. Please verify the email address and click confirm to continue. Click cancel to return to the previous page.
Click "Continue" to clear the consent request form and return to the previous page.
Confirm Continue Cancel Return to form Please verifyYou are granting consent to this member to view and manage your prescription information on MyPrime. This consent will be in effect for one year from the date it is granted.
You are declining consent to this member to view and manage your prescription information. This member will not have access to your prescription information on MyPrime at this time.
Revoking consent will remove this member's ability to view and manage your prescription information on MyPrime, and will be effective immediately.
You are granting consent to this member to view and manage 's prescription information on MyPrime. This consent will be in effect for one year from the date it is granted.
You are declining consent to this member to view and manage 's prescription information on MyPrime. This member will not have access to 's prescription information at this time.
Revoking consent will remove this member's ability to view and manage 's prescription information on MyPrime, and will be effective immediately.
You are canceling your request for consent to view and manage this member's prescription information on MyPrime. Please click Confirm to continue. Click Cancel to return to the previous page.