To submit a prior authorization online, please click the button below to use the web form.
PDF forms are available below to submit a prior authorization through fax.
| Title | Categories | Update Date | Download |
|---|---|---|---|
|
FDA Medwatch Form 1 2243 downloads |
90degrees, affirmedrx, BCBSAL, BCBSFL, BCBSMN, Credence, HiLab, oreadrx, pcarx, rxsense, scriptwellrx, verusrx | May 6, 2024 | Download |
|
ScriptWellRx General Prior Authorization Request Form 1 262 downloads |
scriptwellrx | October 17, 2024 | Download |
|
ScriptWellRx GLP-1 Prior Authorization Request Form 1 94 downloads |
scriptwellrx | October 17, 2024 | Download |