DOWNLOADS | PRIOR AUTHORIZATION
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).


Instructions

To obtain a Prior Authorization, you must:
  1. Print and submit this form to your doctor’s office. When the form is complete, it is to be returned to EHIM.
  2. 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.