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The form collects patient and prescriber identifiers, requested drug details, and whether the case is expedited or urgent, including an explanation of exigency when required. It also gathers Medicare Part B versus Part D determination information, drug dispensing location, diagnosis and diagnostic codes, and prior documentation such as chart notes and lab results, then requires prescriber signature and date.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/humana-pharmacy-solutions-pa-request-form-prior-authorization-request/283965/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/humana-pharmacy-solutions-pa-request-form-prior-authorization-request/283965.png","ImageObject",442,249,{"name":88,"@type":89},"Pentious","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":40},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"When is prior authorization required for this form?","Question",{"text":108,"@type":109},"Certain pharmacy drug benefit requests require prior authorization and additional information from the prescriber. For Medicare Private-Fee-For-Service members, prior authorization is not required for medications covered under Part B.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information must be provided about the requested drug?",{"text":113,"@type":109},"The form requires the drug name, directions/SIG, and quantity. It also asks for whether the request is expedited/urgent and details for where the drug will be dispensed.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical and diagnostic details support the request?",{"text":117,"@type":109},"Submit pertinent medical history or supporting documentation such as chart notes and lab results. The form also requests diagnosis, ICD diagnostic codes, and J-Code when applicable, plus specification if another dispensing option applies.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283965,1790254601,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":40,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},1374404730887,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","PRIOR AUTHORIZATION REQUEST FORMEOC ID:  \nUniversal  \nPhone: 1-800-555-2546 Fax to: 1-877-486-2621  \nHumana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.  \nFor Medicare Private-Fee-For-Service members, prior authorization is not required for medications covered under Part B. The information below is needed for a Part B versus Part D determination for these members.  \n\n| Patient name: |  | Prescriber name: |\n| --- | --- | --- |\n| Member/subscriber number:\u003Cbr>Patient date of birth:\u003Cbr>Group number:\u003Cbr>Address:\u003Cbr>City, state, ZIP: |  | Fax: Phone:\u003Cbr>Office contact:\u003Cbr>NPI: Tax ID:\u003Cbr>Address:\u003Cbr>City, state, ZIP:\u003Cbr>Specialty/facility name (if applicable): |\n| Drug name:\u003Cbr>Directions/SIG:\u003Cbr>Quantity: | 􀀃 Expedited/exigent/urgent\u003Cbr>By checking this box, I certify an expedited/exigent/urgent review is required. The member has a health condition that may seriously jeopardize his/her life or ability to regain maximum function. (Please include explanation of exigency in the space below.) |  |\n\nIs this a proactive request for a new plan year? Yes  No  If yes, please provide plan year:   \n(Please note: All reviews will be processed with generic equivalents for brand drugs whenever possible. )  \nPlease attach pertinent medical history or information for this patient that may support approval and sign this form.  \n\n| Q1 . Please provide additional information (e.g. chart notes, lab results) that would be pertinent to the review of the drug requested |\n| --- |\n| Q2 . Please provide diagnosis: * |\n| Q3 . Please provide J-Code, if applicable: |\n| Q4 . Please provide ICD Diagnostic Codes: |\n| Q5 . Please indicate where the drug is being dispensed? *\u003Cbr> Pharmacy dispensed to patient\u003Cbr> Pharmacy shipped to prescriber\u003Cbr> Prescriber dispensed\u003Cbr> Other |\n\nPRIOR AUTHORIZATION REQUEST FORMEOC ID:  \nUniversal  \nPhone: 1-800-555-2546 Fax back to: 1-877-486-2621  \n\n| Patient Name: | Prescriber Name: |\n| --- | --- |\n\n\n| Q6 . If other, please specify: * |  |  |\n| --- | --- | --- |\n| Q7 . Please indicate if this request is a:  New start/ initial request | * |  Continuation/ reauthorization request |\n\nPrescriber signature Date  \nI declare under penalty of perjury under the laws of the United States of America that the information provided is true and correct. This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately. 3149ALL0917-B","cbCaia7fdJbxZJsI","https://ap.wps.com/l/cbCaia7fdJbxZJsI","pdf",99513,"English","# Patient and Prescriber Information\n## Patient identifiers\n## Prescriber identifiers\n# Drug Request Details\n## Drug name and quantity\n## Directions/SIG and dispensing location\n## Expedited/Urgent request\n# Medicare Determination and Request Type\n## Part B versus Part D information\n## New start vs continuation/reauthorization\n# Clinical Support Questions\n## Additional supporting information\n## Diagnosis and diagnostic codes\n## J-Code and ICD codes\n## Other dispensing specifications\n# Certification and Submission","[{\"question\":\"When is prior authorization required for this form?\",\"answer\":\"Certain pharmacy drug benefit requests require prior authorization and additional information from the prescriber. For Medicare Private-Fee-For-Service members, prior authorization is not required for medications covered under Part B.\"},{\"question\":\"What information must be provided about the requested drug?\",\"answer\":\"The form requires the drug name, directions/SIG, and quantity. It also asks for whether the request is expedited/urgent and details for where the drug will be dispensed.\"},{\"question\":\"What clinical and diagnostic details support the request?\",\"answer\":\"Submit pertinent medical history or supporting documentation such as chart notes and lab results. The form also requests diagnosis, ICD diagnostic codes, and J-Code when applicable, plus specification if another dispensing option applies.\"}]","Humana Pharmacy Solutions PA Request Form - PRIOR AUTHORIZATION REQUEST | PDF",1789623581]