DialClerk Directory

Allied Benefit Systems

Pharmacy and drug authorizations

Separate pharmacy-benefit requests from drugs billed under the medical benefit. The PBM and the insurer may use different contacts.

pharmacy prior auth

Pharmacy prior authorization requests — retail and formulary exclusion (fax)

Official page read
Phone800-288-2078Fax

312-281-1636

Retail/specialty pharmacy and formulary exclusion prior authorization forms

Published email

SpecialtyRx@alliedbenefit.com

Specialty pharmacy medical requests

Published hours

Not published in this record

Product, plan and location

commercial
National contact — confirm product and location

Mailing address
Allied Benefit Systems Box 909786-60690 Chicago, IL 60690-9786

Pharmacy prior authorization forms

Retail Pharmacy Prior Authorization Request Form: send completed form with clinicals to this fax; receipt is not a guarantee of benefits. The Specialty Pharmacy Medical Request Form lists the SpecialtyRx email and the same fax for specialty-pharmacy medical requests. Members of plans with a different PBM may be directed to the phone number on the ID card.

View source ↗ · Source checked 2026-10-25 · Specialty pharmacy request form (email, same fax) ↗ · Formulary exclusion PA form (same fax and address) ↗

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Wait time: not establishedBest time from caller reports: not established. Published hours are not a wait forecast.

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Separate pharmacy-benefit requests from drugs billed under the medical benefit. The PBM and the insurer may use different contacts.

Have ready in your secure workspace

  • PBM name and the pharmacy identifiers on the card
  • Drug, formulation and prescription information
  • Prescriber details and previous review reference

Questions to resolve

  • Is this processed under the medical or pharmacy benefit?
  • What is the correct review and submission channel?
  • Is there a separate specialty pharmacy or appeal team?

This is a general administrative checklist, not payer policy or advice about a particular patient. Confirm the current plan instructions.

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