Prescription and Pharmacy Benefit Management: Refer and Save

  • By Phone: 770-676-7337
  • By Fax: 877-457-1345
  • By Email:
  • Online: complete the form below


Referrer Information

Claim Information

Adjuster Information

Nurse Case Manager Information

Patient Information

(last four digits only)

Prescription Authorization

Pharmacy Information

Prescriber Information

Attorney Information

Additional Information

Authorized Medications

File Upload

Prescription and other supporting referral documents may be attached electronically below.