Get Prior Authorization Form If This Is An Urgent Request, Please Call Upmc Health Plan Pharmacy

This guide provides comprehensive instructions for filling out the Prior Authorization Form related to requests. Follow these steps to ensure that your submission is accurate and complete, facilitating a smoother approval process.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Prior Authorization Form and open it in your preferred editor.
2. Begin by filling out the office contact information, including the provider's specialty, first name, last name, phone number, and fax number.
3. Enter the patient's information, including their name, UPMC Health Plan ID number, date of birth, age, and the requested drug along with its strength.
4. Specify the frequency of the medication and the quantity to be dispensed, then indicate whether the request is for a brand or generic medication, as well as whether it is new or ongoing.
5. If the medication is ongoing, provide the date it started and indicate if the member has shown improvement while on therapy by answering 'Yes' or 'No', along with the date of diagnosis.
6. Document the history of medications used to treat the diagnosed condition, including details about each trial, such as start and end dates, strength, frequency, and any adverse reactions or reasons for discontinuation.
7. Include any additional relevant information in the provided space at the end of the form, ensuring all necessary details are covered to support the request.
8. After completing the form, review all entries for accuracy, then proceed to save changes, download, print, or share the filled-out form as required.

Complete your Prior Authorization Form online to streamline your request process.