Prescription Drug Prior Authorization Request Form

Status
PA vs MTM result
Is this a GLP 1?
Specialty
ApproveNotes
DenyNotes
PA Request Notes
SoftDenyNotes
Internal Private Notes
Addtl Fax Notes
Desc
Templates NEW, thoughts?
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
RX Group ID
Enter Member's RX Group ID
**Please note: any errors in submission may result in delays in the prior authorization review process.**
Patient's Phone Number (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Email (optional)
example@example.com
Sponsor
Plan Alert
Prescriber Information
Doctor/Prescriber Name
Practice Name
Contact Name
Contact Phone
Include extension, if needed
Fax
Format: 0000000000.
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. Do NOT provide an email address if you do not wish to receive prior authorization communication via this method.**
Medication Information
Name of Medication
Is this a new start or continuation?
To the best of your knowledge, is the patient due for a refill within the next week?

Other
Is the prescribed medication being used to treat diabetes?
Has a sample been provided to the patient?
**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?
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.
Provide any additional comments/questions here.
You will be notified of an outcome via the contact information provided on the form in 3-5 business days or 2-3 business days for expedited requests. Please do NOT submit multiple requests for the same patient/medication. This will cause further delays in processing time.

To inquire about the status of a prior authorization please email: help@sonapharmacybenefits.com (make sure to provide the patient's name or initials, date of birth, and name of medication) or text our HIPAA compliant text line: 828-552-3983.
Patient PAP Contact
Prescriber PAP Contact
Patient PAP Application
PAP Results
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
Type a question
SpecialtyNote
ProviderNote
GroupID OLD(no longer used)
If you cannot locate the correct GroupID please select "Unknown" from the drop-down options.
Medication Name
Should be Empty:

Prescription Drug Prior Authorization Request Form

Prescriber Information

Medication Information