Prior authorization for pharmacy drugs

• Online through an ePA portal
  • Surescripts
  • CoverMyMeds
  • ExpressPath
• To request a prior authorization form for a member, Request a Medical Exception
  • Upon receipt of your request, the PA form will be faxed to the requesting provider
  • Fax the completed prior authorization form to 833-951-1680
• Call 877-417-1822 to initiate a prior authorization by phone

• Online through an ePA portal
  • Surescripts
  • CoverMyMeds
  • ExpressPath
• Fax a prior authorization form to 833-951-1680
  • Standard Medication Prior Authorization Form
  • Chemotherapy and Supportive Care Prior Authorization Request Form
  • Hepatitis C Prior Authorization Form
  • Synagis Prior Authorization Form
• Call 877-417-0528 to initiate a prior authorization by phone

• Online through an ePA portal
  
  • CoverMyMeds
  • ExpressPath
  • Surescripts

• To request a prior authorization form for a member, Request a Medical Exception
  • Upon receipt of your request, the PA form will be faxed to the requesting provider
  • Fax the completed prior authorization form to 833-951-1680
• Call 877-573-1929 to initiate a prior authorization by phone

• Online through an ePA portal
  • Surescripts
  • CoverMyMeds
  • ExpressPath
• To request a prior authorization form for a member
  • Online: Request a Medical Exception
  • Fax: send the completed prior authorization form to 833-951-1680
  • Upon receipt of your request, the PA form will be faxed to the requesting provider

• Call 877-417-1839 to initiate a prior authorization by phone

Community Mental Health Center Providers Only
Prior Authorization requirements for Behavioral Health Medications for CMHC providers in NH:

• CMHC Standard Prior Authorization Form
• Drug Prior Authorization Policies

• Online through an ePA portal
  • Surescripts
  • CoverMyMeds
  • ExpressPath
• Fax a prior authorization form to 877-251-5896
• Call 877-417-1828 to initiate a prior authorization by phone

• Online through an ePA portal
  • Surescripts
  • CoverMyMeds
  • ExpressPath
• Fax a prior authorization form to 877-251-5896
• Call 877-417-1828 to initiate a prior authorization by phone