Follow the steps to properly complete the Prior Authorization Form.

1. Press the ‘Get Form’ button to access the Prior Authorization Form and open it in your preferred editing tool.
2. Begin by entering the provider's contact information, including the first and last name, specialty, phone number, and fax number.
3. Fill in the patient’s personal information, including their name, UPMC Health Plan ID number, date of birth, age, and the drug being requested.
4. Specify the strength of the requested drug, the dosage frequency, and indicate whether it is a new or ongoing medication.
5. Provide the diagnosis information and state the date of diagnosis. If the medication is ongoing, indicate if the member showed improvement while on therapy.
6. Detail any risk factors or medical history, including ulcer type, daily steroid use, anticoagulant use, and any documented allergies. If applicable, elaborate on the type of ulcer or medication used.
7. Document any previous therapies related to the condition. Include drug names, strengths, duration, and reasons for discontinuation of at least two nonsteroidal anti-inflammatory drugs.
8. If there is any additional information relevant to the authorization request, submit it in the space provided on the form.
9. Review all entries for completeness and accuracy to avoid delays due to incomplete responses.
10. Once all information is filled out and verified, save the changes, and either download, print, or share the completed form as necessary.

Take action and complete the Prior Authorization Form online today to ensure timely processing of your medication requests.