The prior prescription authorization forms are used by a doctor’s office to make a request to an insurer or government office if a drug is covered by the patient’s health insurance. The form should list the patient’s name, types of symptoms, and the reason for the drug’s medication over other approved types. After the form is complete it can be emailed or faxed and usually an answer is given between 10 and 14 business days.
Standard Prior (Rx) Prescription Authorization Form – Adobe PDF (Fillable)
Important Note: The medical office of the patient is the party required for filling-in this form, not the patient.
The AETNA prescription prior authorization form is a document that is used to justify the prescribing of a particular medication not already on the AETNA formulary. The patient’s personal insurance information, their current condition, and the previous drugs/therapies attempted to remedy their condition must be supplied. If prior authorization has been granted, the insurance company will pay for either a part or the entire cost…
The Amerigroup Prior Prescription (Rx) Authorization Form will be necessary for any Amerigroup member if they wish to receive compensation for non-preferred medication or one which is outside of FDA labeling. The form should be downloaded and completed in its entirety by the individual prescribing the medication, complete with justification for the prescription. As noted on the form, submissions of this nature are reviewed based on medical…
The Anthem Blue Cross / Blue Shield prior authorization form is a simple document used to request a non-formulary drug for a patient and member of Anthem Blue Cross/Blue Shield. The prescriber should complete the document in full, answering the series of yes or no questions which will enable the reviewer to determine whether medical coverage is justified. The likely-hood of receiving coverage is often…
The Catamaran Prior Prescription Authorization Form allows beneficiaries of Catamaran health insurance to receive coverage for a prescription drug which is not on the formulary or not customarily prescribed as the primary treatment option. The prescriber should be the healthcare professional managing the patient’s symptoms and condition, and the form should be completed by this individual with a full justification for the request including all…
The CDPHP Prior Authorization/Medical Exception Request Form is like any other prior authorization form; it’s used to request coverage for a medication that isn’t normally on the insurance company’s formulary. Typically it is necessary that other treatments have been administered, especially those which are more cost effective. If sufficient justification for prescribing the requested medication can be found, CDPHP will cover part or all of the…
The Cigna-Healthspring Coverage Determination Form is available to those healthcare practitioners wishing to provide their patients with the best possible treatment at the most affordable prices. Cigna-Healthspring specializes in assisting Medicare and Medicaid beneficiaries, and it is those patients who are covered under their Medicare Part D Prescription Drug Plan that will be able to employ the attached form. The coverage determination form is a blanket…
The CIGNA Prior Authorization Form is a simple, one-page document that allows healthcare providers to request coverage for atypical medication or those that would require coverage determination. The prescriber’s rationale for seeking prior authorization for the non-formulary request must be provided in order to justify their decision. Often forms of this nature are most effective when the alternative, formulary medication that was administered to the…
The CVS Caremark Prior Authorization Request Form can be used to request coverage for a non-formulary medication or one which is more expensive than those which are typically covered by the insurance company. The below form must be completed in its entirety by the medical practitioner prescribing the drug. The healthcare professional must supply the member and prescriber information as well as the justification for prescribing…
In order to request that EmblemHealth add a drug to their formulary, an individual will be required to submit their Pharmacy and Therapeutics Commitee Addition to the Formulary Request Form. Although there is no specific form for requesting prior authorization for a drug, EmblemHealth’s online PromptPA allows patients and prescribers to request coverage. A link for this website has been provided below. For those wishing…
The EnvisionRX Prior Prescription (Rx) Authorization Form allows prescribers to request coverage for a particular treatment, one which generally isn’t covered by the insurance company. Supporting information and pertinent medical history should be defined within the form in order to plead the case for the patient. Any previously used medications should be mentioned as well to indicate to the insurance company that other solutions have been attempted…
The Express Scripts Prior Prescription (Rx) Authorization Form is a document that is used by a patient’s prescriber in order to request that a certain non-preferred or non-formulary medication be covered under their insurance policy. It will be required of the prescriber that they provide justification for why they’re choosing to prescribe an alternative drug, one which is atypical and, usually, less cost effective for the…
The Fidelis Prior Prescription (Rx) Authorization Form allows a prescribing physician to request coverage for a prescription drug. This document is not required if the drug is already on the insurance provider’s formulary; however, should all other formulary medications prove insufficient in treating the patient’s illness, coverage for non-preferred/non-formulary drugs can be obtained. The prescriber will need to fill out the below form in full, providing…
The Future Scripts General Prior Authorization Request Form is a document that can be faxed into Future Scripts to request coverage for a medication which is generally not on the company’s formulary. The prescriber will need to provide justification for selecting the medication in question to treat the patient’s symptoms. Often previous drugs and treatments have been applied prior to administering this form; each one…
The Harvard Pilgrim Healthcare Medication Request Form can be used for a number of purposes, one of which is prior authorization. Prior authorization allows the prescriber to request coverage for their patient prior to prescribing the preferred medication. Often this is required if the prescription drug being administered is atypical. The healthcare provider must complete the form in full, providing a list of previously applied…
A Humana Prior Prescription (Rx) Authorization Form is required when additional information is needed to determine financial coverage of specific prescription medication. In each of the below linked documents, all fields will need to be filled to enable the insurance company do establish whether or not there is sufficient evidence to justify coverage for the patient in question. As an alternative to filling out a PDF and…
The Medicaid Prescription Drug Prior Authorization Form is a document used by Medicaid beneficiaries to request coverage for a drug that is not on the formulary. That is to say, a drug which is often more expensive and therefore not on the preferred drug list (PDL). The healthcare practitioner prescribing the medication may be able to access a state-specific form for prior authorization. However, the one…
The Medicare Prior Prescription Authorization Form or Medicare Part D Coverage Determination Request Form is used to request financing for a non-preferred medication by the insurance company in question. Some Medicare plans have their own specific document which they prefer to use; however, the below universal form can be sent to all Medicare providers. Once completed with all the patient’s and physician’s information, along with the rationale for prescribing…
The Meridian Medication Prior Authorization Form is one that can be used to request coverage for a prescription medication. An authorization request of this variety will need to be completed by the healthcare provider and sent either online through the Meridian Prior Authorization website or via fax using the state-specific forms linked on this webpage. Alternative medication is usually granted coverage providing that formulary medication has been…
A Molina Healthcare Prior Prescription (Rx) Authorization Form can be used to request coverage for drugs that Molina Healthcare requires justification for prescribing. Along with the patient and prescriber information, the healthcare professional requesting the drug will need to specify their reasoning for doing so, including a list of diagnoses, other medication used in attempt to treat the diagnoses, and all relevant clinical information to support…
The OptumRX Prior Authorization Request Form is a simple form to be filled out by the prescriber that requests that a certain treatment or medication be covered for a patient. A list of tried and failed medication must be provided as a justification for the request alongside the diagnosis. This info will allow those at OptumRX to determine whether or not partial or full coverage is feasible….
A PriorityHealth Pharmacy Prior Authorization Form is a way for plan members to receive coverage for non-covered medication. This form should be completed by the prescriber or healthcare professional in order to provide sufficient justification for the necessity of the non-formulary to treat their patient’s current diagnosis. The below form can be used for commercial, medicaid and MIChild insurance. Once completed, fax to 1 (877) 974-4411…
The Providence Prescription Drug Prior Authorization Request Form is a document that is used to acquire coverage for prescription medication which requires authorization, that is, drugs that are not automatically covered by the member’s health plan. Prescribers or other authorized representatives will be required to complete the document in full, providing their medical rationale for suggesting this particular medication over other formulary alternatives and listing all…
The SilverScript Medicare Prescription Drug Coverage Determination Form is used to request coverage for a non-formulary medication prior to the healthcare provider prescribing it. While this particular document can be used for coverage determination in general, those seeking compensation for a drug prior to prescribing it to their patient will be able to specify that this is in fact a prior authorization request on the…
TUFTS’ Prior Authorization Form can be used by healthcare professionals in Massachusetts and New Hampshire to request coverage for a drug not on the insurance company’s drug formulary. Drugs that require prior authorization are generally those which are specialized, unconventional, or more expensive. This thorough document allows for the healthcare provider to supply ample reasoning for their request which in turn provides the insurance company with…
The United Healthcare Medication Prior Authorization Request Form allows a patient and United Healthcare beneficiary to request coverage for a medication that requires authorization, one that is generally not on the formulary. The prescriber/healthcare professional prescribing the drug will be required to justify their choice of the non-preferred medication in paragraph format on the document. If all sections are complete in full and the reasoning behind…
The Wellcare Prescription Drug Coverage Determination Form can be used for prior authorization requests, the demand by a healthcare practitioner that their patient receive coverage for a medication that they deem necessary to their recovery. It is usually necessary that previous therapies have been tried and failed in order for insurance companies to justify the prescribing of a more expensive, non-formulary drug. It is possible for…
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