Silverscript prior authorization form 2026

1. Click ‘Get Form’ to open the silverscript prior authorization form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, member ID, Medicare ID, date of birth, sex, address, city, state, ZIP code, and phone number. Indicate if the patient is a nursing home resident or a home care patient.
3. Next, complete the 'Prescriber and Pharmacy Information' section. Provide details about the prescriber including their name, specialty, DEA number, NPI number, address, city, state, ZIP code, phone number, and fax number. Also include pharmacy information such as name and contact details.
4. In the 'Information for Requested Drug' section, specify the drug name and whether it is brand or generic. Fill in strength, dosage form, quantity per 30 days, whether it is newly prescribed or a refill, directions for use, diagnosis and ICD-9 code.
5. Provide medical justification in the 'Request for Coverage of a Non-Formulary Drug Criteria' section. Explain why formulary alternatives are ineffective or cause adverse effects. Document previous treatments attempted and any adverse effects experienced.
6. Finally, ensure all fields are completed accurately before submitting your request. Once done, save your changes and follow instructions to submit via fax.

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