Illinicare Health Prior (Rx) Authorization Form

Updated December 31, 2021

An Illinicare Health Prior Authorization Form allows a prescriber to request coverage for a proposed medication to the patient’s medical insurance provider. If your patient is a member of Illinicaire Health, you will be required to submit the Illinicare Health Prior Authorization Form which you can find attached to this webpage. 

How to Write

Step 1 – In Provider Information, enter your full name, your specialty, your fax number, your phone number, and an office contact name.

Step 2 – In Member Information, enter the member’s full name, their ID number, their date of birth, and any medication allergies that they may have.

Step 3 – In the Drug Information section of the form, you will be asked to provide the drug name and strength, dosage, dosage interval, quantity, relevant diagnosis, and the expected length of therapy. Next, you will be asked to indicate whether the member is currently being treated with this medication and if there will be a change in dosage or quantity.

Step 4 – Next, you will need to list the drug name, dates of therapy, and the reason for discontinuation of any other medications that you have prescribed your patient for this condition.

Step 5 – In the Rationale for Request box, describe your justification for requiring this particular medication and coverage.

Step 6 – Last of all, at the bottom of the page, you are required to provide your signature and the date.