Get Upmc Prior Authorization Form

Completing the Upmc Prior Authorization Form is essential for obtaining approval for specific medications. This guide will walk you through each section and field of the form to ensure accurate completion and submission.

Follow the steps to fill out the Upmc Prior Authorization Form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the contact information for the provider in the designated section. This includes the provider's specialty, first name, last name, phone number, and fax number. Ensure all details are typed or printed legibly.
3. Next, fill in the patient’s information. Include the patient's name, UPMC Health Plan ID number, date of birth, age, and the drug requested. Also, specify the dose, frequency, and quantity to be dispensed.
4. Indicate whether the request is for a new medication or an ongoing medication. If it is ongoing, provide the date the therapy started.
5. Answer the question regarding whether the member showed improvement while on therapy by selecting 'Yes' or 'No'.
6. In the medical history section, indicate the primary diagnosis by checking the appropriate box, such as bipolar disorder or schizophrenia.
7. For past medication history, fill in the details of all antidepressants tried. For each medication, provide the drug name, strength/frequency, dates of therapy, and reason for discontinuing.
8. If is being used in combination with an SSRI or SNRI, specify the details of those medications in the provided fields.
9. Finally, include any additional information that might support the need for an exception in the designated space at the end of the form.
10. Once all sections are completed, review the form for accuracy. You can then save your changes, download the completed form, print it, or share it as needed.

Complete the Upmc Prior Authorization Form online to ensure timely processing of your request.