Rxb.promptpa.com Form. If you have 10 or fewer drugs, please select the direct member reimbursement tab. Web medication prior authorization request form.
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Up to 10 drugs with different dates of fill can be requested at one time. Use get form or simply click on the template preview to open it in the editor. Web complete rxb promptpa com online with us legal forms. Fax the completed form to 888.610.1180. You may have received a letter regarding this particular prior authorization. Web medication prior authorization request form. Incomplete form will delay the coverage determination. Easily fill out pdf blank, edit, and sign them. Please fill out all sections. Use the cross or check marks in the top toolbar to select your answers in the list boxes.
A unique number assigned to the pa request. You may have received a letter regarding this particular prior authorization. Fax the completed form to 888.610.1180. Download the rxbenefits prior auth request form. Up to 10 drugs with different dates of fill can be requested at one time. Web description of service start date of service end date of service service code if available (hcpcs/cpt) for direct member reimbursement: If so, your eoc will be included on the letter. We encourage you to use our new online tool, promptpa — a quick and easy method for submitting prior authorization requests for both pharmacy benefit and medical benefit drugs. A unique number assigned to the pa request. Incomplete form will delay the coverage determination. Please fill out all sections.
