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, and contact details.
3. Next, complete the 'Prescriber and Pharmacy Information' section. Include the prescriber's name, specialty, DEA number, and pharmacy details.
4. In the 'Information for Requested Drug' section, specify the drug name, whether it is brand or generic, strength, dosage form, quantity per 30 days, and directions for use.
5. Provide a diagnosis and ICD-10 code to support your request. If an expedited review is necessary due to health concerns, indicate this at the top of the form.
6. Complete the 'Medical Justification' section by detailing why formulary alternatives are ineffective or cause adverse effects. Attach additional pages if needed.
7. Finally, ensure all fields are filled accurately before submitting. Once completed, fax the form to 1-855-633-7673 as instructed.

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