Prescription Drug Prior Authorization Request Form

Status
PA vs MTM result
ApproveNotes
DenyNotes
PA Request Notes
SoftDenyNotes
Internal Private Notes
Addtl Fax Notes
Prescription Drug Prior Authorization Request Form

*CoverMyMeds is NOT used for prior authorizations.* Complete this form to initiate a prior authorization through Sona Benefits. If you have any questions call Sona Benefits at 844-550-1984 or email: help@sonapharmacybenefits.com.
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
GroupID*
If you cannot locate the correct GroupID please select "Unknown" from the drop-down options.
Client
Plan Alert
Prescriber Information
Doctor/Prescriber Name*
Practice Name*
Contact Name*
Contact Phone*
Include extension, if needed
Fax*
Email Address
Please note: an email address is not required but may be provided if it is the preferred method of receiving prior authorization communication.
Medication Information
Name of Medication*
Is this a new start or continuation?

New start.Continuation.
Is the prescribed medication being used to treat diabetes?
Has a sample been provided to the patient?

YesNo
**Please submit the patient's most recent A1C value (and any history available) along with past tried/failed therapies. Failure to do so will result in delays.**
Approximately when did the patient receive the sample, and what quantity was given? *
Specialty
Indication/Diagnosis*
SUPPORTING DOCUMENTATION: Attach office visit note(s) including past tried & failed therapies as well as all relevant labs. If unable to attach documentation, please fax notes to 828-575-5449. *Failing to provide supporting documentation will delay the prior authorization process.*

Cancelof
If expedited review is needed, please select below. Expedited reviews are for urgent or time-sensitive medications.

Expedited Review Needed
Provide any additional comments/questions here.
Patient PAP Contact

Patient ContactedPatient Pending
Prescriber PAP Contact

Prescriber ContactedPrescriber Pending
Patient PAP Application

Patient Application CompleteApplication Pending
PAP Results

ApprovedIneligibleDeniedResult Pending
PAP Approval Date
PAP Exp Date
PAP Plan Savings Per Month
Sona Max Fee Per Month
PAP Plan Savings Per Year
PAP Days Supply
Ryver Task URL and/or PAP and/or Notes
New Therapy (only for MTM)
New Cost (only for MTM)
FaxEmail
example@example.com
PAEmail
pa@sonapharmacy.com
StepTherapyNote
SpecialtyNote
ProviderNote
Medication Name
Should be Empty:

Prescription Drug Prior Authorization Request Form

Prescriber Information

Medication Information