This form is used for providers to request an appeal after a coverage determination or prior authorization has been denied. Your medical provider will complete it with appropriate documentation and mail or fax to True Rx Health Strategists. Your doctor's office needs the address and fax number on the form.

A Prior Authorization is the process in which information regarding a certain medication is gathered and clinically evaluated to determine if the prescription benefit plan will cover their portion of the medication cost. Some plans set limits on certain medications due to age, efficacy, cost, and availability.

If a prior authorization is needed, your doctor's office will need to complete this form. Instructions, including contact information, are included on the form.

The True Rx Prior Authorization (PA) and Utilization Management (UM) program utilizes drug specific clinical criteria tailored to formulary and plan requirements.  Medications subject to clinical review are evaluated according to criteria developed from the following sources:

• FDA approved indications

• Treatment guidelines

• Clinical practice guidelines

• Peer-reviewed medical and pharmacy literature (including randomized controlled trials), and evidence-based medicine reviews

• Medical and pharmacy tertiary resources

Prior Authorization requests should include:

• Completed prior authorization form

• Recent clinical notes (within last 6 months)

• Relevant laboratory results

• Clinical support for use of the medication

Occasionally, you may be eligible for a refund from True Rx Health Strategists if a medication was not covered initially at the pharmacy. If this is the case, simply download the drug reimbursement claim form and follow the instructions. Mailing instructions are included at the bottom of the page.