Will this checklist get a medication covered?

No. Coverage and documentation requirements depend on the plan, product and reason for use. Obtain the plan’s current requirements and coordinate with the prescribing office. The CMS source concerns Medicare prescription drug coverage determinations; other plans may use different procedures. 1

Can I save my worksheet?

Yes. Download a text file or use Print / save as PDF. Entries stay in browser memory and are not emailed or saved to your Sipra account. Clearing or reloading the page removes them from the page, while files and printouts you saved remain under your control.

What should I confirm before records are sent?

Confirm the exact product, the plan’s current form, who will submit it, the secure submission method and any plan-supplied deadline. Keep sensitive records out of this browser worksheet.

Does a denial mean there are no next steps?

Not necessarily. Ask the plan for the reason, the applicable appeal instructions and any deadline. The prescribing office can explain what it can submit; the worksheet cannot decide whether an appeal will succeed.

Prepare for a prior authorization request

FAAFP, DABOM · Medical reviewer of record · Updated September 14, 2026 · September 14, 2026

Prepare for a prior authorization request

Turn your plan’s requirements into a document checklist to discuss with the prescribing office. Requirements vary by plan, medication and reason for use.

Entries stay in this page and disappear when you clear or reload it. Downloads and printouts remain wherever you save them. Avoid names, birth dates, member IDs and other identifiers.

Plan or benefit type (optional; no member ID)

Requirement to clarify with plan or prescriber

Deadline supplied by your plan (optional)

Ask the plan whether the exact product and indication require prior authorization.Obtain the plan’s current request form and submission instructions.Ask the prescriber which records the plan requires and who will submit them.Confirm a secure method for sharing records; do not place records in this worksheet.Ask how to track the request and what to do if it is denied.Record any plan-supplied deadline and appeal instructions.

This worksheet organizes information for a conversation. It does not verify a prescription, choose treatment or assess safety.

A worked example

Fictional example, not personal medical information

Plan or benefit type (optional; no member ID): Example plan (fictional)
Marked complete by you: Ask the plan whether the exact product and indication require prior authorization.
Still to check: Obtain the plan’s current request form and submission instructions.

The example shows the output format. Use your own verified information and take unresolved questions to the appropriate professional.

Run your own numbers in the tool above.

Using this tool

Turn your entries into a useful record

Turn your plan’s requirements into a document checklist to discuss with the prescribing office. Requirements vary by plan, medication and reason for use. Entries are assembled into a downloadable worksheet. Marking a check complete records your own action; it does not certify a medicine, pharmacy or document.

This worksheet organizes information for a conversation. It does not verify a prescription, choose treatment or assess safety.

Keep the request specific

Record the exact product, reason for use, current plan requirement and who owns the next step. Do not enter a member ID, medical record or other sensitive document into this browser worksheet.

Before you finish

Separate facts from open questions

Check	What to capture
Plan information	Current form, submission channel and any plan-supplied deadline
Prescribing office	Who submits records and who tracks the response
Still unclear	Coverage criteria, missing documents and appeal instructions

This page keeps entered details in browser memory. It does not email them or save them to your account. Clear or reload the page to remove the entries. Downloaded files and printouts remain under your control.

Continue with a related tool or browse all tools.

Frequently asked questions

Every medication on sipra is prescribed by a licensed physician, so your care always starts with a visit. Your sipra membership gives you ongoing access to those physician visits, so you can check in, adjust your plan, and ask questions whenever you need, without paying per visit. It is how we keep high-quality care convenient: one membership, physician access whenever you need it, and support at every step.

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Sources

CMS prescription drug coverage determinations; Medicare-specific source www.cms.gov

This worksheet organizes information for a conversation. It does not verify a prescription, choose treatment or assess safety. Medical reviewer of record: Jillian Foglesong Stabile, MD, FAAFP, DABOM. Updated September 14, 2026. Sources checked September 14, 2026.

Compounded medications are not FDA-approved and require a patient-specific prescription. Brand names are trademarks of their owners; sipra is not affiliated with them.

Prepare for a prior authorization request

Jillian Foglesong Stabile

Prepare for a prior authorization request

A worked example

Turn your entries into a useful record

Separate facts from open questions

Frequently asked questions

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Prepare for a prior authorization request

Prepare for a prior authorization request

A worked example

Turn your entries into a useful record

Separate facts from open questions

Frequently asked questions

What is the sipra membership?

Will this checklist get a medication covered?

Can I save my worksheet?

What should I confirm before records are sent?

Does a denial mean there are no next steps?

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