Meridian Prior (Rx) Authorization Form

Updated June 02, 2022

A Meridian prior authorization form is made for medical offices to fill out when requesting coverage for a non-preferred drug. A physician may be able to secure insurance coverage and obtain clearance to prescribe the proposed medication once the below form has been completed and submitted for review. Meridian has also provided an online prior authorization form for all interested parties.

By State

How to Write

Step 1 – Enter the Date of Request.

Step 2 – In Patient Information, you will need to provide the patient’s name, their member ID number, their gender, their date of birth, and their phone number.

Step 3 – In Prescriber Information, enter your name and specialty, your NPI number, your office phone number, your office fax number, and list an office contact person.

Step 4 – In the Diagnosis and Medical Information, enter the type of medication, the strength and route of administration, the frequency, the patient’s height and weight, the expected length of therapy, the quantity, the patient’s BMI and date calculated, the patient’s blood pressure and the date it was taken, the related diagnosis, and any drug allergies that the patient may have.

Step 5 – Beneath Rationale for Prior Authorization, you must write your justification for requesting this medication/prescription. Then, list the name, the reason for failure and the date of failure for any other medication that this patient has taken to treat this diagnosis.

Step 6 – Finally, you must include the most recent relative laboratory results to accompany your submission.