Specialty Medication Pre-Authorization Request
Patient Information
Full Name
Date of Birth
Phone
Member ID
Prescriber Information
Prescriber Name
NPI
Phone
Fax
Medication Requested
Name
Strength
Directions
Quantity
Duration (days)
Diagnosis & Clinical Information
Diagnosis/ICD-10 Code
Relevant Clinical Information
Previous Therapies
List Previous Medications / Therapies Tried
Additional Notes