Prescription Drug Coverage Determination Request Prior Authorization

Sometimes a drug requires prior authorization. In those cases, your doctor must provide medical information to support the request for the drug before it will be covered. This additional step helps ensure the drug is being used safely and appropriately.

Use the Elixir PromptPA tool below to ask for a drug coverage determination. This form can be filled out by a member, a member’s appointed representative or the prescribing doctor or provider.

Note: Virginia Premier Medallion 4.0 members will need to add “*VPM4” to the end of the member ID number when using the Elixir PromptPA tool. For example: 12345678912*VPM4 

Elixir PromptPA Tool