Get Unicare Prior Authorization Form

Filling out the Unicare Prior Authorization Form correctly is essential for ensuring that your request for medication is processed efficiently. This guide provides a step-by-step approach to completing the form online, helping users navigate each section with ease.

Follow the steps to complete the online form accurately.

1. Press the ‘Get Form’ button to access and open the Unicare Prior Authorization Form in your preferred online document editor.
2. Begin by filling out the member information section. Enter the last name, first name, and middle initial of the member. Indicate the member's place of residence by selecting either 'Home' or 'Nursing facility' as applicable.
3. In the medication information section, provide the drug name and strength being requested. Also, enter the UniCare ID number, height, date of birth, weight, dosage instructions (SIG), diagnosis or indication for the medication, and the member’s sex.
4. If applicable, detail any previous medications the member has tried for their condition, including drug names, strengths, and the date range of use. Otherwise, explain why no alternatives were attempted.
5. Discuss any adverse reactions or inadequate responses experienced by the member and provide a brief overview in the allotted space. Mention any pertinent details that may support the request.
6. Clearly describe the medical necessity for any non-preferred medications or prescriptions that fall outside FDA labeling guidelines in the provided section.
7. List all current medications being taken by the member, including dosage and frequency, as well as any additional relevant information.
8. Complete the diagnostic studies and laboratory tests section by listing all tests related to the diagnosis that were performed within the past 30 days, detailing dates and results.
9. In the prescriber information section, enter the prescriber's last name, first name, NPI number, DEA/license number, service address, and relevant contact information.
10. Fill out the billing facility information, including the facility name, NPI/Tax ID, address, and contact details.
11. Provide the pharmacy information by listing the pharmacy name, NPI number, and contact details.
12. Confirm the accuracy of the information by signing the form either by the prescriber or an authorized representative. Include the date of signature.
13. After completing the form, save your changes. Depending on your needs, you can download, print, or share the completed Unicare Prior Authorization Form.

Complete your Unicare Prior Authorization Form online today to ensure swift processing of your request.