Status
Please Select
PA Approved
PA Denied
PA Soft Denied
PA Review
PA Request
Misc. PA Communication
MTM In Progress
MTM Approved
MTM Denied (PA Approved)
PA vs MTM result
Please Select
PA
MTM
PA & MTM (MTM denied and PA approved)
ApproveNotes
Please Select
approved through
DenyNotes
Please Select
medication not on formulary
need subscriber info
missing documents
hasn't met step therapy
patient not active SB member
PA Request Notes
Please Select
diabetic medications
general medications
SoftDenyNotes
Please Select
missing information
plan not active
Internal Private Notes
Addtl Fax Notes
Sona Benefits Prior Authorization
Complete this form to initiate a Prior Authorization through Sona Benefits. Be sure to include all relevant labs (i.e. most recent A1C for diabetes prior authorizations) -missing information may cause a delay in processing. *CoverMyMeds is NOT used for Prior Authorizations* If you have any questions please call Sona Benefits at 844-550-1984
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
GroupID
*
Please Select
UNKNOWN
00495
00495RBP
1445BASE
1445BUY
1445HDHP
178BASE
178BUY
18301AF
18301AS
18301B
2583
2889
288T
3382
4736
4736A
526H
526T
5288B
5288S
5828
63310
6331E1
6331EF
6331EO
6331PE1
6331PEF
639HSA
639PPO
641M1
641M2
641PLAN1
641PLAN2
644BASE
644BUY
646MC
646MC2
646MP
656HD
674M
676LP
676PPO
678M
681PA
681PB
681PC
681PD
6821H
6821T
683BASE
683BUY
684RX
686MH
686MP
694BUY
694CORE
701HSA
701PL
702MP
702MP2
702MP3
703P
703PF
704MC
704MCD
706BAS
706BUY
707CHS
707CP
707HSA
707MP
707MPF
707MPV
708HD
708P
709CG
714C
716BA
716BU
716MA
716MU
7181B
7181G
7181P
7181S
718P1
718P2
720101
720102
720103
720104
720105
720506
725BASE
725BUY
7265HRA
7265HSA
7265HSAF
7265HSAS
7266HRA
7266HSA
7266HSAF
7266HSAS
7855A
7855B
7BASE
7BASEH
7BUY
7BUYH
816C
816H
816L
816M
8228
8228DME
8321H
8321P
8345
8345C
9803
CC01F
CC01S
CC02F
CC02S
CC03F
CC03S
CC04S
CC05F
CC05S
CC07S
GE4483C
GE4483L
GE4483T
GH4483C
GH4483L
GH4483T
H103
H151HD
H151TR
HINF
HINI
HINO
HIWF
HIWI
HIWO
KBRP50
LONF
LONI
LONO
LOWF
LOWI
LOWO
MBH3
RX1743
RX2228HDHP
RX228PPO
RX4102
RX831
RX83A
RX83B
RX83B2
RX83C
RX919
WCMS
YM1
YM1R
YM2
YM2R
YM3
YM4
YM5
YM5R
YM6
YM6R
Client
Plan Alert
Doctor/Prescriber Information
Doctor/Prescriber Name
*
Practice Name
*
Contact Name
*
Contact Phone
*
Include extension, if needed
Fax
*
Medication Information
Name of Medication
*
Specialty
Please Select
Yes
No
Is the prescribed medication being used to treat diabetes?
Please Select
No
Yes
If "yes" please submit the patient's most recent A1c value (and any history available) along with past tried/failed therapies.
Is this a new start or continuation?
New start.
Continuation.
Indication/Diagnosis
*
Supporting Documentation - Attach office visit note (s) including past tried & failed therapies as well as all relevant labs. If unable to attach documentation, please fax notes to 828-575-5449. *Failing to provide supporting documentation will delay the prior authorization process
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If expedited review is needed, please select below. Expedited reviews are for urgent or time-sensitive medications.
Expedited Review Needed
Provide any additional comments/questions here.
Submit
Patient PAP Contact
*
Patient Contacted
Patient Pending
Prescriber PAP Contact
*
Prescriber Contacted
Prescriber Pending
Patient PAP Application
*
Patient Application Complete
Application Pending
PAP Results
Approved
Commericial Insurance
Denied
Result Pending
Annualized Savings
Exp Date
Current Cost
New Therapy (only for MTM)
New Cost (only for MTM)
Ryver Task URL and/or Notes
Group ID OLD
StatusOLD
PA vs MTM result OLD
FaxEmail
example@example.com
PAEmail
pa@sonapharmacy.com
MonthYear
StepTherapyNote
SpecialtyNote
ProvideNote
Medication Name
Should be Empty: