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PRIOR AUTHORIZATION REQUEST FORM EOC ID: EnvisionRxOptions Tev-Tropin Prior Authorizationr r rPhone: 866-250-2005 Fax back to: 877-503-7231 r ENVISION RX OPTIONS manages the pharmacy drug benefit

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telecopy futher tropin Q5 rPhone EOC Q1 Prescriber EnvisionRxOptions Q2 NPI RX rOther tev Q3 Lic Q4 Authorizationr rExpedited endogenous illegible disclosing secretion prescribing ENVISION sender disclosure recipient pertinent copying

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