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.