A Prior Authorization is an approval for a specific drug or class of drug that is excluded from your benefit plan, and does not allow coverage without a statement of medical necessity provided by the requesting physician. Please see your plan or talk with your benefits administrator about specific details, or call our Help Desk at 800-311-3446 for more information.
Download the form (PDF)
To obtain a Prior Authorization, you must:
- Print and submit this form to your doctor’s office. When the form is complete, it is to be returned to EHIM.
- Also fill out and return the Medical Release form.
After both of these forms have been submitted, and a decision has been made, both the member and the doctor’s office will be notified. Please be aware that co-payment for Prior Authorized medications may not be standard brand/generic co-pays. Please refer to your Pharmacy Employee Handbook
The form should be printed, filled out and then faxed or mailed to EHIM. EHIM's fax number is 248-948-9904.