SAV-RX Prior (Rx) Authorization Form

Updated January 23, 2022

An SAV-RX prior authorization form is used by prescribing physician’s to request a specific drug treatment plan for their patient. Some medications are not covered by certain insurance plans, therefore, the doctor must disclose their medical reasoning for prescribing the patient this particular drug when other cheaper, generic drugs might be used instead. The physician must complete the prior authorization form and send it in to SAV-RX for review. Not all prior authorization requests will be approved, at which point the patient must choose between paying for the drug out of pocket or treating themselves with a cheaper medication.

  • Form can be faxed to: 1 (888) 810-1394

How to Write

Step 1 – Enter the plan/medical group name, phone number, and fax number at the top of the page.

Step 2 – The first section involves patient information. Enter your patient’s first name, last name, phone number, address, D.O.B., gender, height, weight, allergies, and (if applicable) the patient’s authorized representative and their phone number.

Step 3 – Under “Insurance Information”, enter the patient’s primary and secondary insurance name and their ID number.

Step 4 – The next section asks for “Prescriber Information”. Provide your first and last name, specialty, address, requestor, office contact person, NPI number, phone number, DEA number, fax number, and email address.

Step 5 – In the “Medication” section, enter the name of the requested drug. Select new therapy or renewal and, if renewal, enter the date therapy initiated and duration of said therapy. Below that, fill in the necessary information of this previous therapy. Next, provide the dose, frequency, length of therapy, and quantity of the new prescribed medication. You must also include how it will be administered and where.

Step 6 – Section (1) on the second page asks if any other treatment has been prescribed to the patient to help their condition. If you select yes, enter the names of these previous medications, how long it was prescribed for, and why it didn’t work.

Step 7 – Provide your diagnosis of the patient and include ICD-9/ICD-10.

Step 8 – Include any other comments that could strengthen your reasoning behind your diagnosis and the prescribing of this particular medication.

Step 9 – Include your signature and the current date at the bottom.