Since July 1, 2021, Illinois law has required every prescribing provider to use this uniform form when a commercial insurer requires prior authorization for a prescription drug, and every insurer must accept it. You send it to the patient's health plan or its PBM. If the insurer fails to respond to a completed, accurate request within 24 hours for urgent needs or 72 hours for regular needs, the request is deemed granted.
The prescribing provider completes Sections A through J and signs the Section J representation. The insurer adds its contact and submission details to page 1 before posting the form, and page 4 is reserved for the health plan's approval or denial.
The box at the bottom of page 1 holds the insurer's or PBM's contact and submission details. Company Bulletin 2021-09 told insurers to add this information before making the form available to providers, so use the copy posted by the patient's plan. The page also reminds you to read the plan's website for anything else its reviewers need and to send the form to the plan only, never to the Department of Insurance.
At the top of page 2, check one review type. An expedited request certifies that a standard review period may seriously jeopardize the patient's life, health or ability to regain maximum function. Only for an expedited request, give the provider's direct contact phone number and your initials. The insurer then has 24 hours to respond to a completed, accurate urgent request, versus 72 hours for regular medication needs.
Mark Initial Authorization Request, Renewal Request or DAW (dispense as written). The note under this section repeats that the form does not cover medical exceptions under Sections 25(a)(3) or 45.1 of the Managed Care Reform and Patient Rights Act, so a step therapy or formulary exception request needs the plan's own forms rather than this one.
Answer whether the patient is hospitalized, then enter the patient's name, date of birth, street address with unit or apartment, city, state, ZIP code, phone number and sex. Add the patient's health plan ID and, if applicable, the group number. Copy the ID exactly as it appears on the member card so the plan can match the request to the right coverage.
Give the prescribing provider's name, NPI and specialty, plus a DEA number for controlled substance requests only. Enter an office contact name, phone, street address with suite, city, state and ZIP, and the contact fax. Email is optional, and the health plan provider ID is requested only if accessible. The plan uses these contact details for follow-up questions and to send its decision.
Section D asks only for the pharmacy name and phone. In Section E, enter the drug name, strength, dosing schedule and duration, a specific diagnosis with its ICD code, and, if applicable, the place of infusion or injection and the facility provider ID or NPI. Indicate whether the patient has already started the medication and when, and list the ingredients within the drug.
Explain why the drug is needed, drawing on the history of present illness, past medical history and current medications. The form invites you to attach chart notes if they will assist the review. This is where reviewers look for the clinical case, and the instructions warn that insufficient clinical information may extend the review period or lead to an adverse determination.
If applicable in your opinion, list prior drugs in Section G with strength, dosing schedule, duration and the adverse event or specific failure for each. Section H is optional space for other information you consider necessary, such as relevant diagnostic labs, measures and the patient's response to treatment. Specific dates, durations and outcomes help the reviewer apply the plan's criteria.
The prescribing provider prints a name, signs and dates the form, representing that the information is true, complete and fully disclosed to the best of their knowledge and belief. The form warns that providing false or deceptive information with intent to defraud may be insurance fraud. Page 4 is marked For Health Plan Use Only and records the approval, denial, reviewer and effective date.
Download the current version from the source each time; forms change without notice.
Illinois Uniform Electronic Prior Authorization Request Form for Prescription Benefits
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Under 215 ILCS 5/364.3(f), if an insurer receives a completed and accurate request on Form 3643 and fails to use or accept the uniform form, or fails to respond within 24 hours for urgent medication needs or 72 hours for regular medication needs, the prior authorization request is deemed granted.
No. The form says it does not apply to medical exception requests under Sections 25(a)(3) or 45.1 of the Managed Care Reform and Patient Rights Act, which may require additional information and their own forms. Contact the patient's health plan to obtain the appropriate exception forms.
Only for controlled substance requests. Section C asks for your name, NPI and specialty, an office contact name, phone, address and fax, and your health plan provider ID if you can access it. The DEA field is marked as required for controlled substance requests only, and the contact email is optional.
Yes. Section F asks for the rationale, such as history of present illness, past medical history and current medications, and says you may attach chart notes if you believe they will help the review. Section H gives optional space for diagnostic labs, measures and response to treatment.