Prior Authorizations

CAUTION: Please be sure to select the correct fax number on the Authorization Form for your county/service area. Use of an incorrect fax number may cause unnecessary delays in getting your authorization request to the appropriate medical review team.

Please remember that patient confidentiality and privacy is protected under HIPAA, so using the correct form and fax number will ensure to protect you against inappropriate disclosures.

Medical Prior Authorizations

• 2024 Prior Authorization Request Form
• 2024 Medicare Prior Authorization Grid
• Medical and DME (Including Diabetic Supplies) Prior Authorization Request Form
• Referral vs. Prior Authorization

Part D (Pharmacy) Prior Authorizations

Please submit an Online Coverage Determination Form, an Electronic Coverage Determination through CoverMyMeds

OR you may submit an: ATRIO Medimpact Medicare Part D Coverage Determination Request Form

CoverMyMeds Instructions / Tutorial

Click below to watch a tutorial for more information on using CoverMyMeds, including:

• How to log in
• Submitting a new ePA
• Checking the status of an existing request
• Renewing a request