Prior Authorization Form

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Please fill out the online form below and attach supporting documentation for a faster review and response.

You can also fax it to: (804) 800-2585

For questions, please email us at: priorauth@disrupt-rx.com

If you have a general coverage question about a specialty medication, reach out to  Disrupt-Rx at specialty@disrupt-rx.com or call/text (619) 720-6466