Use this form to initiate a prior authorization request for your Medicare Part D medication. This form cannot be used to request fertility drugs, drugs for weight loss or weight gain, drugs for hair growth, drugs for erectile dysfunction, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).
Your prescribing provider must provide a statement to support your request. When we receive your request, we will contact your provider to obtain the necessary information.
* Indicates a required field.