Get Upmc Prior Auth

Filling out the Upmc Prior Authorization form for compounded medications is a straightforward process that ensures your request is processed efficiently. This guide provides step-by-step instructions for filling out the form online, helping you to submit accurate and complete information.

Follow the steps to complete the Upmc Prior Auth form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing all the required fields in the form. Start with the office contact details, including provider specialty, first name, last name, phone, and fax.
3. Next, fill out the patient’s information, including their name, UPMC Health Plan ID number, date of birth, and age.
4. Indicate the name of the compound medication along with its strength, dosage frequency, and quantity to be dispensed.
5. Specify whether the medication is a new or ongoing treatment, and provide the diagnosis. If the medication is ongoing, include the date it started and indicate whether the member showed improvement during the therapy.
6. Answer the question regarding the medication’s use for a work-related injury. If applicable, list the date of injury.
7. Select the requested dosage form from the options provided: capsule, liquid, topical cream, suppository, or other.
8. List each ingredient in the compound, along with the total amount of each ingredient and the number of capsules or volume of liquid to be dispensed.
9. Include details of any previous therapies tried, including their effectiveness and reasons for discontinuation.
10. Finally, provide any additional information that may be relevant to the request in the designated space before submitting.

Submit your UPMC Prior Auth form online to ensure timely processing.