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Prior Authorization Form //// ONLY COMPLETED REQUESTS WILL BE REVIEWED Drug Requested: (check one) Date: Patient ID#: DOB: Patient Name: Provider NPI: Prescribing Physician: Office Contact: Office

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Lyricapristiqsavellaaplenzinbgraliseb - amerihealth medicare is a medication management program provided by AmeriHealth Medicare that covers certain prescription drugs.

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Individuals who are enrolled in the AmeriHealth Medicare plan and are prescribed any of the listed medications are required to participate in the program.

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Patients can fill out the necessary forms either online or through their healthcare provider to enroll in the program.

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Patients are required to report any changes in their medication regimens, medical history, or side effects experienced while taking the prescribed medications.