Prior Authorization Web Form
In order to use this online form, please enable JavaScript.
Select Form
Biologic Immunomodulators Initial
Biologic Immunomodulators Renewal
CGRP Inhibitors (Aimovig, Emgality, Ajovy) Initial
CGRP Inhibitors (Aimovig, Emgality, Ajovy) Renewal
Constipation Agents (Amitiza, Linzess, Trulance)
Diabetic Glucagon-like peptide agonists (GLP-1) (Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza). This is a closed formulary. Do not submit requests for NON-FORMULARY Adlyxin, Bydureon or Byetta. Non-formulary drugs are not subject to prior authorization review. Please submit questions to info@pcarx.com or fax to 210-624-8896.
Opioids (Extended Release)
Opioids (Immediate Release)
Stimulants [Provigil (modafinil), Nuvigil (armodafinil)]
Topical products for atopic dermatitis [Protopic (tacrolimus), Elidel (pimecrolimus), Eucrisa]
Weight Loss Agents (generic stimulants, Qysmia, Saxenda, Wegovy). This is a closed formulary. Do not submit requests for NON-FORMULARY Contrave or Xenical. Non-formulary drugs are not subject to prior authorization review. Please submit questions to info@pcarx.com or fax to 210-624-8896.
Other - Not Listed
Select
Request Information
Check if Urgent
Note: The prescriber attests that applying the standard turnaround time could seriously jeopardize the life, health, or safety of the member or others, due to the member’s psychological state, or in the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.
Request Type
Request
Appeal
Patient Information
First Name
Last Name
Middle Name (optional)
Phone Number (optional)
Address (optional)
City
State
State
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
ZIP Code (optional)
Format: 5 digits
Date of Birth
Format: mm/dd/yyyy
Gender
Gender
Male
Female
Other
Height (optional)
Weight (optional)
Allergies (optional)
Appointed Rep. (AOR) (optional)
AOR Phone Number (optional)
Insurance Information
Primary Insurance Name
Primary Insurance ID Number
Secondary Insurance Name (optional)
Secondary Insurance ID Number (optional)
Prescriber Information
NPI Number (individual)
First Name
Last Name
Specialty
Loading...
Address
City
State
State
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
ZIP Code
Phone Number
Fax Number (in HIPAA-compliant area)
Email Address (optional)
DEA Number (if required)
Office Contact Person (optional)
Requestor (if not the prescriber)
Medication/Medical and Dispensing Information
Medication to Search For
Partial matches are allowed, starting with the beginning of the medication's name.
(minimum of 3 characters required)
Search for Medication
Loading...
Quantity
Days Supply
Frequency
Total Number of Fills
Pharmacy Name (optional)
Pharmacy Phone Number (optional)
Pharmacy Fax Number (optional)
New Therapy
Renewal
Dispense As Written
Note: If not checked, the request will be reviewed as "Generic Substitution Permitted"
Date Therapy Initiated (if renewal)
Date format: mm/dd/yyyy
Duration of Therapy (specific dates)
Administration
Oral/SL
Topical
Injection
IV
Other
If Other, please explain
Administration Location
Physician's Office
Ambulatory Infusion Center
Patient's Home
Home Care Agency
Outpatient Hospital Care
Long Term Care
Other
If Other, please explain
Has the patient tried any other medications for this condition?
Yes
No
If Yes, complete the three fields below.
Medication/Therapy (Drug Name and Dosage)
Duration of Therapy (Specify Dates)
Reason for Failure/Response/Allergy
Diagnoses
List of Diagnoses
ICD-10 Codes (if available)
Clinical Information
Please provide all relevant clinical information to support a prior authorization review.
Clinical Explanation
List of Current Medications
Additional documentation included in attachments
Additional Attachments
PDF files only. Maximum of 50 pages per attachment. Larger documents should be faxed to (833) 676-2016.
Attestation
I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, Insurer, Medical Group, or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.
Signature (enter name)
Signature Date
Format: mm/dd/yyyy
Submit Request
Confidentiality Notice:
The documents accompanying this submission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please arrange for the return or destruction of these documents immediately.