SilverScript Prior (Rx) Authorization Form

Updated June 02, 2022

A SilverScript prior authorization form is required in order for certain drug prescriptions to be covered by an insurance plan. Insurance policies have their limitations and, in some cases, a physician must complete and submit the SilverScript prior authorization form in order to get approval for the drug they intend to prescribe to their patient. The prescribing doctor has to justify their reasoning and explain why that specific drug (as opposed to generic or less expensive options) is completely necessary for the patient’s condition. If any necessary information is excluded on the prior authorization form, SilverScript may not approve coverage of the drug.

  • Form can be faxed to: 1 (855) 633-7673

How to Write

Step 1 – The first section of the SilverScript prior authorization form, “Enrollee’s Information”, requires that you provide your name, date of birth, physical address, phone number, and member ID#. (If the person making the request is representing the enrollee, complete the second section as well.)

Step 2 – Write the name of the prescription drug you are requesting at the top of page two (2).

Step 3 – Select one of the options under “Type of Coverage Determination Request” and include any additional information at the bottom that might help support your claim.

Step 4 – Next, a signature is required from the enrollee, or the enrollee’s prescriber or representative. Include today’s date.

Step 5 – The prescriber must complete the “Prescriber’s Information” section and include their signature and the date at the bottom.

Step 6 – In the “Diagnosis and Medical Information” section, enter the following information: medication, strength and route of administration, frequency, new prescription OR date therapy initiated, expected length of therapy, quantity, height/weight, drug allergies, and diagnosis.

Step 7 – The prescriber must indicate the reason for this request by ticking one of the boxes under the “Rationale for Request” section. An explanation is needed if their reason is not listed above.