Prior Authorizations & Referrals

If Prior Authorization (PA) is required, the Primary Care Provider (PCP) or specialty care provider will complete the Prior Authorization Form, attach supporting documentation and fax to the Prior Authorization Department. Some medications (including non-generic medications) require Prior Authorization. To request an authorization for a medication that is not listed on the formulary but is reimbursable, please complete a non-formulary drug prior authorization and fax to the number listed within the Pharmacy Prior Authorization Form (see below).

• Services that are outside the scope of the PCP, may be referred to a contracted specialty care provider. The PCP will complete the Referral Form or acceptable substitute and fax it to the specialty care provider’s office along with applicable test results and other pertinent documents.
• Primary care providers, specialists, hospitals, and vendors should fax Prior Authorization requests to the Prior Authorization Department.
• If PA is not required, per the Prior Authorization Grid, the PCP must refer the patient with a form of written instruction (i.e., note on prescription pad or Referral Form) with reason for visit (consult only – consult & treat, diagnosis, findings, etc.) to present to the specialty care provider.
• Specialty care providers must obtain Prior Authorization from the Prior Authorization Department for all services as listed on the Prior Authorization Grid.