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This form may be sent to us by mail or fax: Address: SilverScript® ? I request prior authorization for the drug my prescriber has prescribed.*. ? I request an Appeals if you have Medicare prescription drug coverage You or your prescriber believes that a coverage rule (like prior authorization) should be waived. 3 Oct 2016 Access fax forms to request prior authorization to cover a Medicare Part D drug. If your drug is not listed, use a general fax form. Office use only: General_CMS_2013Sep.doc. Prior Authorization Request Form. Member Information(required). Provider Information (required). Member Name:. Office use only: General_CMS_2016Oct.doc. Prior Authorization Request Form. DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY 22 Mar 2017 All our forms are listed on the Drug prior authorization request forms page. for Medicare Prescription Drug Determination form (31KB PDF). Prescription drug prior authorization request form for Medicare & Medicaid Services (CMS) as those uses of a covered Part D drug that are approved under the 2017 Request for Medicare prescription drug coverage determination. (You must complete both pages.) Please fax completed form to: 1-800-408-2386 Note: Members under 65 years of age are not subject to the prior authorization. Prior Authorization can ensure proper patient selection, dosage, drug administration and duration of Download Non-Medicare Prior Authorization Forms. gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and Rationale for Exception Request or Prior Authorization.
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