EnvisionRx Prior (Rx) Authorization Form

Updated December 31, 2021

An EnvisionRx prior authorization form is a document used by a physician when seeking approval for a patient’s prescription. Once complete, the form will specify important details regarding the patient’s diagnosis, which in turn will allow EnvisionRx to ascertain whether or not the patient’s insurance plan covers the prescription cost. Have the form completed in its entirety before sending it by fax to EnvisionRx.

  • Fax: 1 (877) 503-7231
  • Phone: 1 (866) 250-2005

How to Write

Step 1 – In the upper left portion of the form, write the patient’s name, member number, group number, full address, and phone number.

Step 2 – In the upper right portion of the form, write the prescriber’s name, fax number, and phone number. Also, give the office name, NPI, State Lic ID, and full address.

Step 3 – In the next set of fields, specify the name of the drug and whether or not you would like to expedite the delivery process. Include any specific directions here.

Step 4 – In “Q1”, specify whether the request is for initial or continuing therapy. If continuing therapy, indicate the start date (MM/YYYY).

Step 5 – In “Q2”, indicate the patient’s diagnosis for the requested medication.

Step 6 – In “Q3”, indicate the quantity of medication that is being requested per 30 days.

Step 7 – In “Q4”, indicate the anticipated duration of therapy.

Step 8 – In “Q5”, list all other medications the patient has previously tried for the indicated diagnosis. Include the specific dates and outcomes (e.g. ineffective, adverse reaction, etc.).

Step 9 – In “Q6”, provide a unique peer-reviewed journal article to support the request along with any medical information that may support approval (off-label use only).

Step 10 – Lastly, have the physician give their signature and date the form.