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
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First Name
Last Name
Patient DOB
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Month
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Day
Year
Date
Doctor/Prescriber Information
Doctor/Prescriber Name
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Practice Name
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Contact Name
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Contact Phone
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Include extension, if needed
Fax
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Medication Information
Name of Medication
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Indication/Diagnosis
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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
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