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Silverscript prior authorization form 2026
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- Click ‘Get Form’ to open the silverscript prior authorization form in the editor.
- Begin by filling out the 'Patient Information' section. Enter the patient's name, Member ID, Medicare ID, date of birth, and contact details.
- Next, complete the 'Prescriber and Pharmacy Information' section. Include the prescriber's name, specialty, DEA number, and pharmacy details.
- 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.
- 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.
- Complete the 'Medical Justification' section by detailing why formulary alternatives are ineffective or cause adverse effects. Attach additional pages if needed.
- 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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silverscript prior authorization form
Prior authorization: If a drug requires a new prior authorization, share the formulary with your provider to determine if a formulary alternative may beRead more
Nov 22, 2024 Without Part D Plans 800-294-5979. The pharmacy benefit manager will assist your physicians office with completing a prior authorization form.Read more