Prior Authorization for Prescription Drugs

Submitting a Request for Prior Authorization

To request coverage of a medication requiring prior authorization, please follow the steps below.

1. Consult Ventegra's library of medication policies to see if the medication has specific prior authorization criteria. (Not applicable for Mosaic Life Care.).
2. Download the Prescription Drug Prior Authorization Request Form.
3. Complete all applicable sections. This form is a fillable PDF so you can enter the information electronically. Or you can print the blank form and fill it out legibly by hand.
4. Sign the request form.
5. Fax the completed, signed form to: 1-855-336-6612 and be sure to include any additional information that is important for the review (e.g. chart notes or lab data).