Pharmacy Medication Request

Providers submitting a request on behalf of patients covered under Fairview/Ebenezer, Mille Lacs Band of Ojibwe, North Memorial, Thermo King, or Hopkins School District, should use the ClearScript Prior Authorization Form. Requests should be submitted directly to ClearScript at FAX 1-855-875-7443.

Requesting a medication or the completion of this form does not ensure coverage. Please check the member's prescription benefit plan. Please follow-up with PreferredOne Customer Service (800.997.1750 Option #3) for status of this request.

Check the status of any past requests.

Reason for Request

Please complete a separate request for more than one medication.