The Rightway prior authorization form is a one-page request your prescriber completes and submits to Rightway’s pharmacy benefit team to get a medication covered before the pharmacy fills it. You can download the PDF from rightwayhealthcare.com/members/pharmacy-information, and your prescriber submits it electronically through CoverMyMeds (the preferred route) or by fax to 888-498-1038.1Rightway Healthcare. Pharmacy Information The form only applies to prescription drugs, not hospital stays or surgical procedures. If you need help with any part of the process, Rightway’s pharmacy team is at 888-665-1678.
Check the Drug List First
Before anyone fills out a form, confirm the medication actually requires authorization. Rightway publishes a combined prior authorization and step therapy drug list on the same pharmacy information page as the PDF.1Rightway Healthcare. Pharmacy Information If the drug is covered under your plan’s tier without restrictions, no form is needed and the pharmacy can fill the prescription normally. If it appears on the list, keep reading.
Your prescriber’s office can pull the form through CoverMyMeds, which pre-populates some fields, or download the same PDF and complete it on paper.2Rightway Healthcare. PBM Resources for Providers and Pharmacists
How to Complete Each Section
The form has six sections. Work through them in order. A blank field is the fastest way to get the request bounced back.
Request Type
Two checkboxes sit at the top: Standard Request and Expedited Request. Check expedited only if waiting for a standard decision could seriously harm your life, health, or ability to regain maximum function. That phrasing is on the form itself, and reviewers apply it literally. Marking a routine refill as expedited won’t speed it up; Rightway will process it on the standard timeline anyway.
Patient and Prescriber Demographics
You enter your name, date of birth, sex, and Pharmacy Benefits ID number. The Pharmacy Benefits ID is on your insurance card and may be different from a general medical member ID, so check the card before writing it down.
The prescriber section asks for the provider’s name, ten-digit NPI, specialty, phone, fax, pharmacy name, pharmacy phone number, and a direct office contact with extension. Rightway uses that office contact to reach someone who can answer clinical questions quickly.
Medication Information
Enter the drug name, strength, frequency, quantity dispensed, and day supply. A generic-versus-brand checkbox appears here; Rightway substitutes generics automatically unless the prescriber marks “Brand Necessary.” Indicate whether the medication is new or a continuation of existing therapy. For continuations, the form requires a start date and chart documentation showing you improved while on the drug.3Rightway Healthcare. General Authorization Form Missing that documentation is one of the most common reasons continuation requests get denied.
Billing Information
This section determines how the drug is billed. Check “Pharmacy” if the pharmacy dispenses the medication directly to you. Check “Medical” if the drug is administered in a doctor’s office or hospital and billed under the medical benefit, and enter the applicable J-code and ICD-10 diagnosis code. Select the place of administration: physician’s office, hospital or clinic, or patient home.3Rightway Healthcare. General Authorization Form
Clinical Information
Enter the diagnosis and date diagnosed. A medication history table follows, where the prescriber lists every drug previously used to treat the same condition, each entry including strength, frequency, dates of therapy, and the reason it was stopped. A checkbox is available if no prior medications have been tried. Reviewers spend the most time on this section. Thin entries here invite denials. Attach recent lab results, imaging, or office notes in the open space at the bottom if they strengthen the medical-necessity case.
Attestation and Signature
The prescriber signs or provides electronic ID verification, attesting that the information is true and accurate. The form warns that Rightway may audit the request and pull the underlying medical records to verify what was reported.3Rightway Healthcare. General Authorization Form
Step Therapy and Exception Requests
Some medications on Rightway’s formulary carry a step therapy requirement, which means you have to try one or more lower-cost alternatives before the plan covers the requested drug. The combined prior authorization and step therapy drug list tells you if your medication falls under that rule.
If you’ve already tried and failed the preferred alternatives, or there’s a clinical reason they’re inappropriate, your prescriber can request a step therapy exception on the same form. The medication history table is where this argument lives. For each previously tried drug, document the name, strength, dosage, dates of therapy, and the specific reason it was stopped: side effects, allergic reaction, or lack of effectiveness. Attach lab reports or test results that support the exception. If you were approved for the medication under a prior health plan and are transitioning coverage, documentation of that approval or a valid claim history from the last 90 days can support a continuation request.
Submitting the Form
Electronic submission through CoverMyMeds is Rightway’s preferred route. Rightway-specific forms are available on the CoverMyMeds platform, where the prescriber’s office can complete and transmit the request digitally without printing or faxing.2Rightway Healthcare. PBM Resources for Providers and Pharmacists Electronic submission generates a confirmation and lets the office track status online.
If faxing is the only option, the number is 888-498-1038. Include a cover sheet with the prescriber’s NPI and your Pharmacy Benefits ID so the intake team can route the request correctly, and attach all supporting documentation, including lab results, office notes, and records of failed therapies, behind the form. Faxed submissions don’t generate automatic confirmations, so the prescriber’s office should call provider services at 888-665-1885 to confirm receipt.
Members who want direct help can reach Rightway’s pharmacy team at 888-665-1678 or chat through the Rightway app. Rightway also offers a health guide service that can coordinate with your doctor and pharmacy to manage prior authorizations on your behalf.4Rightway Healthcare. Rightway Members – Healthcare Support – Benefits Navigation
How Long the Decision Takes
For employer-sponsored plans governed by ERISA, federal rules set the clock. A standard pre-service decision is due within 15 days. Rightway can extend that by another 15 days if the delay is beyond its control, but it must notify you before the first 15-day window closes, explain the reason, describe any additional information it needs, and give you at least 45 days to supply it.5eCFR. 29 CFR 2560.503-1 – Claims Procedure
Urgent requests, meaning those where the expedited box is checked and clinical urgency is real, must be decided as soon as possible and no later than 72 hours after the plan receives the request.6U.S. Department of Labor. Filing a Claim for Your Health Benefits If Rightway determines the request doesn’t meet the urgency threshold, it processes the claim on the standard 15-day timeline and notifies you of the reclassification.
You and the prescriber both get a decision notice. An approval includes an authorization number and an expiration date, which is the window during which the prescription must be filled. Keep the authorization number; the pharmacy needs it to process the claim. Expiration periods vary by plan and medication, so note the date and schedule your fill accordingly.
If the Request Is Denied
A denial notice must spell out the specific clinical reasons the request was turned down, the plan provisions behind the decision, a description of any additional information that could change the outcome, and your right to appeal.5eCFR. 29 CFR 2560.503-1 – Claims Procedure Read the letter carefully. Sometimes the fix is as simple as supplying a missing lab result or correcting a diagnosis code.
For group health plans, ERISA gives you at least 180 days from receiving the denial to file an internal appeal.5eCFR. 29 CFR 2560.503-1 – Claims Procedure You can submit written comments, additional medical records, and any other supporting information. The plan must give you free copies of the documents it relied on if you ask. A different reviewer, one who wasn’t involved in the original denial, evaluates the appeal. The strongest appeals include a letter from the prescriber explaining why the denied medication is medically necessary for your specific situation, plus any new clinical evidence that wasn’t in the original submission. When the denial was based on step therapy, documentation of adverse reactions to the preferred alternatives carries significant weight.
If the internal appeal is also denied, you can request an external review by independent reviewers outside the health plan. External review is available for denials involving medical judgment, determinations that a treatment is experimental, or a coverage cancellation. You have four months from the final internal denial to file a written request. Standard external reviews are decided within 45 days; expedited external reviews are decided within 72 hours. The cost is either nothing or no more than $25 per review, and the insurer is legally required to accept the external reviewer’s decision.7HealthCare.gov. External Review
What Happens if You Skip Prior Authorization
If a required prior authorization isn’t obtained before the prescription is filled, the plan will almost certainly refuse to pay. Who ends up with the bill depends on the plan’s rules and how the claim is coded. The provider’s office often absorbs the cost when the responsibility for securing authorization fell on the prescriber. In other situations, particularly when the plan places the authorization burden on the member or when you see an out-of-network provider without pre-approval, you may be personally responsible for the full cost of the medication.
True emergencies are generally exempt from prior authorization, but the plan may retroactively review whether the circumstances actually qualified. If that review decides they didn’t, the claim reverts to the standard authorization rules and may be denied. The safer path is to have your prescriber submit the request before you fill the prescription, even if it means a short wait. If you need the medication immediately, ask the prescriber to check the expedited box and call provider services at 888-665-1885 to flag the urgency.