State-specific forms:

• California
• Colorado
• Indiana
• Massachusetts
• Michigan
• New Mexico
• Oregon
• Texas

How to Write

Step 1 – Begin by downloading the document in Adobe PDF.

United Healthcare Medication Prior Authorization Request Form

Step 2 – Beginning filling out the form on your computer or in black/blue ink. The first section will need the member information. This will require all of the following:

• Full name
• Member ID
• Address
• Phone number
• DOB
• Allergies
• Primary insurance
• Policy number
• Group number

At the bottom of this window, you will have to specify whether this is a new request or a continuation of a therapy. If it’s a continuation, provide the start date of the therapy initializing. Check “Yes” or “No” to indicate whether the patient is hospitalized.

Step 3 – Physician information is next. Supply their full name, address, phone and fax number. Their NPI#, specialty must also be entered along with the name of the office contact.

Step 4 – In “Section C” is where you’ll need to enter the medication’s specifications and give your reasoning and evidence for why the selection is medically necessary. Enter the following in the available fields:

• Medication
• Strength
• Directions for use
• Quantity
• Diagnosis
• ICD-10 Code
• If the member is pregnant and the due date (if applicable)
• Why you’re choosing this medication over one which is listed as “preferred”

Step 5 – Previous medication trials must be submitted to help justify the request. Enter each medication, strength, directions, dates of therapy and reasons for failure in the table presented at the bottom of the form. Date the document and supply it with a signature before faxing it to: (866) 940-7328.

How to Write

Step 1 – Download the document in Adobe PDF to start.

Medicare Prior Prescription (Rx) Authorization Form

Step 2 – Under “Patient Information,” supply their name, member ID#, full address, phone number, sex, and date of birth.

Step 3 – The prescriber’s full name, NPI number, address, office phone, office fax, and office contact person must be entered in the second window.

Step 4 – In the “Diagnosis and Medical Information” window, you will have to enter the following data:

• Medication
• Strength and route of administration
• Frequency
• New prescription or date of therapy initiated
• Length of therapy
• Quantity
• Height/weight of patient
• Patient drug allergies
• Diagnosis

Supply the day’s date where applicable but leave the prescriber’s signature field empty until the document has been printed.

Step 5 – In this window, you will need to provide the rationale for prior authorization. Select the applicable box and if the rationale is not supplied under the first four (4) options, check the last box and provide the explanation below. If the document should be expedited due to the condition of the patient, check the appropriate box at the bottom of the form.

Step 6 – Print the document, provide your signature and fax the form to the patient’s healthcare plan to complete the process.

How to Write

Step 1 – Download the Global Medicaid Prior Authorization Form in PDF to begin.

Medicaid General Prior Authorization Form

Step 2 – The top-most fields will require the plan/medical group name, phone number, and fax. Below this, under “Patient Information,” supply the following data:

• Full name
• Phone number
• Address
• Date of birth
• Sex
• Height
• Weight
• Allergies
• Authorized rep name and phone number (if applicable)

Step 3 – The patient’s primary and secondary insurance name and ID numbers will be required as applicable.

Step 4 – The prescribing physician will then have to supply their personal information. All of the below data must be submitted in the empty fields.

• Name
• Address
• Specialty
• Requestor (if different than prescriber)
• Office contact person
• NPI number
• Phone number
• DEA number
• Fax number
• Email address

Step 5 – The name of the medication can be entered in the top-most field of this window. Identify whether this is a new therapy or a continuation. If a renewal, indicate the duration of therapy and the date the therapy was initiated. If it is a renewal, you will also need to explain how the patient received the medication.

The dosage, frequency of use, length of therapy, and quantity requested of the drug must be indicated. Below this, supply the administration method and location by selecting the appropriate box.

Step 6 – The patient’s name and ID# can be supplied at the top of the second page. Under window number one (1), indicate whether or not the patient has tried other medications in order to justify the reasoning for prescription of the non-formulary medication. If yes, complete the windows below requesting information on previously tried and failed alternatives.

Step 7 – The second window asks that you list the diagnoses as well as the corresponding ICD-9/10 codes.

Step 8 – All clinical information which will help plead the case for coverage, and the necessity of the non-preferred drug can be entered in the bottom-most field. If you plan to attach evidence, check the attachment box and supply whatever documents will help support your claim.

Step 9 – Read the attestation, and supply the day’s date. Once printed, sign the document (if you are the prescriber) and fax the completed form to the appropriate state department.

How to Write

Step 1 – Download the form in Adobe PDF.

Wellcare Prior Prescription (Rx) Authorization Form 

Step 2 – The enrollee’s name, DOB, address, phone number, and enrollee member number will need to be provided in the first section.

Step 3 – Next, submit the requestor’s name, relationship to enrollee, full address, and phone number. It should be noted that this is only applicable if the person making the request is not the enrollee or the prescriber.

Step 4 – Submit the name of the drug being request, as well as the strength and quantity request for each month (if possible).

Step 5 – In the “Type of Coverage Determination Request” window, select the prior authorization option.

Step 6 – Any additional information that should be considered by Wellcare can be submitted in the available fields here or attached with supporting documents. If a decision is needed within 24 hours, check the applicable box. Provide the date and, when printed, your signature.

Step 7 – Again, if you need the form expedited, check the box on this page. Next, enter the prescriber’s info. The following will be necessary:

• Name
• Address
• Office phone
• Office fax
• Signature (once printed)
• Date

Step 8 – The “Diagnosis and Medical Information” section will need to be completed with the following data:

• Medication requested
• Strength and route of administration
• Frequency
• New prescription or date therapy was initiated
• Expected length of therapy
• Quantity
• Height of enrollee
• Weight of enrollee
• Drug allergies of enrolee
• Diagnosis

Under “Rationale for Request” select the applicable option. If the rationale is not present, select “Other” and provide explanation.

Step 9 – Once the document has been completely filled out and double checked for any errors, you may print it off, provide all necessary signatures, and send the document to Wellcare via Fax for processing.

• New Hampshire Prior Authorization Form
• Massachusetts Prior Authorization Form

How to Write

Step 1 – Download the state-specific form above to begin the request process. Once open on your computer, proceed to the next step.

TUFTS Prior Prescription (Rx) Authorization Form

Step 2 – Select either “Initial Request” or “Continuation/Renewal Request” to start. Below that, select the reason for the request (in this case prior authorization) and, if this is an “urgent request,” check the applicable box.

Step 3 – Under “Patient Information,” supply their name, date of birth, gender, and member number.

Step 4 – The prescriber information is slightly more involved. Enter all of the following:

• Clinician’s name
• Phone number
• Specialty
• Fax number
• NPI number
• DEA/xDEA
• Prescriber contact person (if applicable)
• Contact person’s phone
• Contact person’s fax
• Contact person’s email (optional)
• Signature (once printed if filling online)
• Date

Step 5 – Window “D” asks for the information relating to the medication being requested. Supply the name, strength, dosing schedule, quantity, therapy length, and date therapy is initiated. If the patient is currently being treated with the request drug, check the appropriate box and provide the start date. Check “Yes” or “No” when asked if the DAW is specified and, if “Yes,” supply your rationale

Step 6 – Answer whether or not the medication is a compound and, if it is, provide a list of its ingredients. Include citation to peer reviewed literature if applicable.

Step 7 – In section “F” you can enter the primary diagnosis related to the request, the accompanying ICD codes, and pertinent comorbidities.

Step 8 – In this section, the following can be provided:

• Drug allergies
• Member height
• Member weight
• Concurrent medications
• Opioid management tools in place (if applicable)

Step 9 – List the details relating to each previously attempted therapy for the patient’s diagnosis.

Step 10 – Check the appropriate checkbox for each of these questions. If the answer is “Yes” to either, provide the requisite details.

Step 11 – Under “Relevant Lab Values,” if applicable, provide lab name and value and the date of each test. If the request is for a renewal, check the appropriate box relating to any improvement while on the therapy. If the answer is “Yes,” describe. Any additional information for the request can be provided in the bottom field here.

Step 12 – This window is to be completed for “Professionally Administered Medications”. Supply all requisite information if this applies.

Step 13 – Once all data has been entered into the form, you can print it off, provide the aforementioned signature, and fax it with any other supporting documents to (617) 673-0988. 

How to Write

Step 1 – Begin by downloading the PDF file and opening it up on your computer.

SilverScript Prior Prescription Authorization Form

Step 2 – Next, the plan member’s information must be supplied. Enter their full name, DOB, full address, phone number, and enrollee member ID#.

Step 3 – This section is to completed specifically if the individual making the request is not the enrollee OR the provider. The requestor’s name, relationship to enrollee, full address, and phone number.

Step 4  – Select the type of coverage determination request being performed. In this case, select the third checkbox requesting prior authorization.

Step 5  – Any information that should be considered by the insurance company should be provided in the paragraph field here. Any supporting documents can be attached. If a decision is needed with a day, check the box on the bottom of this page.

Step 6 – Provide the date here. Once the form has been printed off, the signature of the individual requesting prior authorization should be supplied in the empty field.

Step 7 -Again, check this box if you’d like to request for expedited review. Under prescriber’s information, the following information must be supplied:

• Name
• Address
• Office phone
• Office fax
• Date
• Signature (once printed)

Step 8 -The diagnosis and pertinent medical info should be entered into this window. This will include the below data:

• Medication name
• Strength and route of administration
• Frequency
• Whether new prescription or date therapy initiated
• Expected length of therapy
• Quantity
• Height/weight of member
• Drug allergies
• Diagnosis

Step 9 – The rationale for the request can be described via checkbox here. Select the applicable option. If not listed, select “other” and provide an explanation.

Step 10 – Once the document has been gone over for any possible mistakes, print it off, provide the aforementioned signatures, and fax the document to: 1 (855) 633-7673. Alternatively, you may mail it to the below address.

SilverScript® Insurance Company
Prescription Drug Plan
P.O. Box 52000, MC109
Phoenix AZ 85072-2000

How to Write

Step 1 – Download the form in Adobe PDF to begin.

PriorityHealth Prior Prescription (Rx) Authorization Form 

Step 2 – Once the form is open on your computer, check whether or not the request is urgent or non-urgent.

Step 3 – The first window requests the member’s full name, ID #, date of birth, gender, and physician’s name. Next supply the following info pertaining to the provider:

• Provider name
• Phone number
• Fax number
• Address
• NPI
• Contact name

Once the form has been printed off, the date of signing and the signature can be supplied.

Step 4  – Here the product information can be supplied. This will require all of the below data.

• Medication request
• Start date
• Strength of medication
• Date of last dose (if applicable)
• Dosing frequency
• Anticipated length of therapy

Step 5 – Here is where the medical reasoning for the non-covered medication can be supplied. List the patient’s medical condition and explain the medical reasoning in paragraph format. A full list of previously attempted drugs to treat the conditions should be supplied and below that, any additional information that may support the argument.

Step 6 – Print off the form, provide the provider signature as mentioned in step 3, then fax the completed form to the numbers found at the top of the page.

How to Write

Step 1 – First you’ll have to download the form. Click here and open up the document in your web browser or PDF viewer of choice.

Providence Health Prior Prescription (Rx) Authorization Form

Step 2 – The first info you’ll need is the patient’s name, member ID and DOB.

Step 3 – Here you can supply all the medical provider’s info. Submit the following:

• Requesting physician/provider’s name
• Specialty
• NPI
• Tax ID #
• Full address
• Phone number
• Fax number
• Contact name, phone, and fax
• Pharmacy name, phone, and fax

Step 4 – Request drug name and strength must be submitted into the first field followed immediately by the quantity and ICD-10. On the second line, enter in the directions, length of therapy and diagnosis.

Step 5 – Here is where the reasoning for prescribing the chosen medication must be justified. Provide a list of previously drugs tried and the dosage of each. Below the table, in paragraph format, supply your medical rationale for the request drug all with any supporting chart and labs notes (attach as separate pages if necessary).

Step 6 – Print off the form once double checked for accuracy, supply the day’s date and your signature then fax the document and any other necessary information to 1 (503) 574-8646 or 1 (800) 249-7714.

How to Write

Step 1 – Begin by downloading the form in Adobe PDF and opening it up in the PDF reader of your choice.

OptumRX Prior Prescription Authorization Form

Step 2 – The first required information is that of the member. Enter their name, insurance ID number, DOB, full address, and phone number.

Step 3 – Next, to the right of the member info, supply the healthcare provider info. This will require the following:

• Name
• NPI #
• Specialty
• Office phone
• Office fax
• Office address

Step 4 – The medication’s name, strength and dosage form must be enter next. If requesting a brand, select the appropriate box. If the physician is supply the medication, check that this is the case. In the two bottom windows, enter in the directions for use and whether or not it is a continuation of a current therapy. If yes, answer the two accompanying questions.

Step 5  – The clinical information window is required. Supply the diagnosis followed by a list of medications that have been tried and failed and the date on which each drug was prescribed.

Step 6  – Check the “yes” box to indicate that all the information provided is both true and accurate. Enter in the date and, once the document has been printed off, sign the signature field. Before doing so however, enter in any other comments, diagnoses, symptoms etc. that will help the reviewing process.

Fax the form, once 100% complete, to 1 (800) 711-4555 if this is an expedited request, or to 1 (800) 527-0531 if the need for the medication could be classified as non-urgent.

• California
• Florida
• Illinois
• Michigan
• New Mexico
• Ohio
• South Carolina
• Texas
• Utah
• Washington
• Wisconsin

How to Write

Step 1 – Download the state-specific form above. For the purposes of our instructions, we’ll cover the California Prescription Drug Prior Authorization Request form.

Molina Healthcare Prior Prescription Authorization Form 

Step 2 – The patient’s personal and medical information will be required first. This will include the following:

• Name
• Phone number
• Address
• DOB
• Sex
• Height
• Weight
• Allergies
• Authorized representative (if applicable)
• Authorized representative number

Step 3 – The name of the patient’s primary insurance and the associated patient ID number should be provided. If applicable, provide the same for the secondary insurance.

Step 4 – The presciber’s info is next. After their full name, specialty, and address have been provided, enter the following:

• Requestor (if different than prescriber)
• Office contact person
• NPI number
• Phone number
• DEA number
• Fax number
• Email address

Step 5 – The name of the requested medication must be supplied here. Next, check whether this is a new therapy or renewal. If renewal provide date therapy initiated and the duration of the therapy. In the window below this, enter how the patient received the medication (paid under insurance or other) and enter the name and prior authorization if it was paid for under insurance. The requested dose/strength, frequency, length of therapy and quantity must be entered in as well. Finally check the applicable box in the administration and administration location windows.

Step 6 – At the top of the second page, supply the patient name and ID#. Next, check “Yes” or “No” answering whether or not the patient has tried other medication for their condition. If yes, fill out the table the requires the medication/therapy name, the duration of said therapy, and the reason for failure. List next the diagnoses and provide the ICD-9/ICD-10 for each.

Step 7 – In the third window of the second page, provide all relevant clinical information to support the PA claim, attaching any applicable documents.

Step 8 – Enter the date of completing the form, print off the document, sign it, then send it into Molina Healthcare for review.