Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member's details, including the Member ID #, Phone #, and Date of Birth (DOB). Ensure that the information is accurate and legible.
3. In the Medication Prior Authorization Form section, indicate if this request is urgent by checking the appropriate box. This option should only be used for requests that could be life-threatening or significantly impact continuous patient care.
4. Fill out the date of request, the patient’s name, and their date of birth. Include the Patient ID number for identification purposes.
5. Provide the pharmacy's information, including the name, contact person, fax number, and phone number to ensure the request is directed appropriately.
6. Input the provider's details, which includes the provider’s name, contact person, signature, phone number, fax number, address, city, state, and zip code.
7. Specify whether this is a new request or a renewal. If it is a renewal, record the date of the original prescription.
8. Detail the medication name and strength requested, including the directions for use and monthly quantity. Indicate the relevant diagnosis and number of refills required.
9. List any preferred medications that have been tried or previous therapy used. Include details such as strength, frequency, and duration.
10. Provide relevant medical justification to support the medication request. This information should be clear and thorough.
11. Once all sections are completed, review the form for accuracy. Users can then save changes, download, print, or share the completed form as required.

Complete your Contra Costa Health Plan Prior Authorization Form online today to expedite your medication requests.