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.
- Consult Ventegra's library of medication policies to see if the medication has specific prior authorization criteria. (Not applicable for Mosaic Life Care.).
- Download the Prescription Drug Prior Authorization Request Form.
- 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.
- Sign the request form.
- 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).