Envision Rx Prior Auth PDF Details

Envision Rx Prior Auth is a free service that helps pharmacists and their patients submit, track, and monitor prescription prior authorizations. The service can help speed up the authorization process for patients who need prescriptions filled quickly. Envision Rx Prior Auth is easy to use – simply create an account, submit a request, and track the status of the authorization. Plus, pharmacists can use the service to communicate with prescribers and insurance providers.

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Form NameEnvision Rx Prior Auth
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesenvisionrx prior authorization form, envisionrxoptions prior form, envisionrxoptions prior authorization request, envisionrxoptions prior authorization form

Form Preview Example



EnvisionRx General Prior Authorization- 1

Phone: 866-250-2005 Fax back to: 877-503-7231

ENVISION RX OPTIONS manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process.

Patient Name:

Member Number:

Date of Birth:

Group Number:


City, State, Zip: Member Phone:

Prescriber Name:




Office Contact:



State Lic ID:



City, State, Zip:


Drug Name:



Please attach any pertinent medical history or information for this patient that may support approval. Please answer the

following questions and sign:

Q1. Is this request for initial or continuing therapy?

Initial therapy

Continuing therapy (Start date MM/YY):

Q2. Please indicate the patient's diagnosis for the requested medication:

Q3. What is the quantity of medication that is being requested per 30 days?

Q4. What is the anticipated duration of therapy?

Less than one month

One to three months

Three months to one year


Q5. Please list all other medications the patient has previously tried for the indicated diagnosis along with the dates and outcomes (e.g. ineffective, adverse reaction, etc):

Q6. IF THE REQUEST IS FOR OFF-LABEL USE you must provide a unique peer-reviewed journal article to support the request. Please attach any medical information that may support approval.

Physician Signature


This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for the return of this document.

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Enter the requested information in each one area to complete the PDF envision rx

envisionrxoptions prior authorization form fields to fill in

Include the essential details in the Q What is the anticipated duration, Q IF THE REQUEST IS FOR OFFLABEL, Physician Signature, Date, and This telecopy transmission section.

envisionrxoptions prior authorization form Q What is the anticipated duration, Q IF THE REQUEST IS FOR OFFLABEL, Physician Signature, Date, and This telecopy transmission fields to fill

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