Sona Benefits Prior Authorization

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 NameLast Name
Patient DOB*

MonthDayYear
Date
Group ID*
Doctor/Prescriber Information
Doctor/Prescriber Name*
Practice Name*
Contact Name*
Contact Phone*
Include extension, if needed
Fax*
Medication Information
Name of Medication*
Medication Name
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

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If expedited review is needed, please select below. Expedited reviews are for urgent or time-sensitive medications.

Expedited Review Needed
Status
PA vs MTM result
PA Exp Date
Current Cost
New Therapy (only for MTM)
New Cost (only for MTM)
Annualized Cost Savings (PA denial and MTM approval)
Group ID
Ryver Task URL and/or Notes
Should be Empty:

Sona Benefits Prior Authorization

Doctor/Prescriber Information

Medication Information