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Prior authorization is not required for emergency services.

Please note that Prior Authorization is not a guarantee of payment. It is a pre-service determination of medical necessity based on information provided at the time the prior authorization request is made. Allegian Choice retains the right to review the medical necessity of services, eligibility for services, and benefit limitations and exclusions after you receive the services. 

Requesting Prior Authorization:

  • Verify member eligibility prior to the provision of services.
  • Complete appropriate referral/authorization form (OB/GYN, Medical or Pharmacy) and attach supporting documentation.
  • Submit request via FAX to 866-315-6314

Medical Prior Authorization

Blast Fax July 18, 2016: Prior Authorization Guideline Updates


Prior Authorization/Referral Form
Prior Authorization List (Effective 7/1/16) 

Pharmacy Prior Authorization 

Allegian Choice has contracted with a Pharmacy Benefit Manager (PBM) called CVS Caremark to oversee our prescription drug program.  Consult the formulary to determine if the medication prescribed requires a prior authorization.  Complete the prior authorization form and submit to CVS Caremark. 

View CVS Pharmacy Prior Authorization information and form 

Fax: 888-836-0730 

Attn: Exchange PA Dept.
1300 E Campbell Rd. 
Richardson, Texas 75081 

Phone: 855-582-2022

PPO - Pre-Certification Requirements

HMO - Pre-Certification Requirements

Prior Authorization Request Form for Health Care Services

Prior Authorization Request Form for Prescription Drug Benefits

Quick Reference Guide