Prior Authorization is a distinction attached to a class or category of drug that does not allow coverage of a medication in that class or category without statement of medical necessity provided by the requesting physician. Prior Authorization is a mutually agreed upon approval or amendment to a pharmacy plan by a plan sponsor, requesting physician and pharmacy administrator for an otherwise excluded medication or drug classification.
Download the form (PDF).
Instructions
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.
- 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.