Prior authorization for medications

Request a PA for a Pharmacy Drug

  • Check the formulary and our pharmacy policies to see if a prior authorization is required for a pharmacy drug.
  • If prior authorization is required, select the member’s plan below for more information on how to submit a prior authorization.

  • Online through an ePA portal
  • To request a prior authorization form for a member, Request a Medical Exception
    • Upon receipt of your request, the PA form will be faxed to the requesting provider
    • Fax the completed prior authorization form to 833-951-1680
  • Call 877-417-1822 to initiate a prior authorization by phone

  • Call 877-417-1839 to initiate a prior authorization by phone

Community Mental Health Center Providers Only
Prior Authorization requirements for Behavioral Health Medications for CMHC providers in NH:

Request a PA for a Medical Drug

Select drugs are available under the Medical Benefit.  

  • Review our pharmacy policies for coverage requirements.
  • If prior authorization is required, fax the appropriate form to 866-539-7185.