[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283807-105":53,"doc-detail-283807-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","pharmacy-prior-authorization-request-form","Pharmacy Prior Authorization Request Form","","Pharmacy Prior Authorization Request Form collects member, prescriber, and dispensing pharmacy details to support review of a requested medication. It captures drug information such as name, strength, dosage form, directions, quantity, refills, and therapy duration, plus whether a brand or generic is requested and continuation status. Clinical sections request diagnosis with ICD-10, contraindication confirmation, prior medication trials with outcomes, and supporting labs or test results, along with optional additional provider rationale. It also includes standard and urgent turnaround selection and signature attestation for accuracy.",{"@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/pharmacy-prior-authorization-request-form/283807/",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/pharmacy-prior-authorization-request-form/283807.png","ImageObject",442,249,{"name":88,"@type":89},"Noah","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-28","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What member details are required on the form?","Question",{"text":108,"@type":109},"The form requests member name, date of birth, gender, BCBSAZ ID number, and address including city, state, and zip code.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which provider and pharmacy fields must be completed?",{"text":113,"@type":109},"It requires the prescribing provider’s name, specialty, NPI, DEA, and office address and contact information, plus the dispensing pharmacy’s name and phone/fax details.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical documentation is needed to justify the prior authorization request?",{"text":117,"@type":109},"The form asks for the diagnosis with ICD-10 code and description, confirmation of absence of contraindications, prior medication trials with response or failure reasons (including that samples are not accepted), and any supporting labs/test results, plus optional additional information from the provider.","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},283807,1790545198,{"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":20,"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},8796095462418,"https://ap-avatar.wpscdn.com/avatar/80000253c1241d02b47?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778826106357471780","| Member Information |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Member Name (first & last): | Date of Birth: |  | Gender: |  | BCBSAZ ID\\#: |\n| Address: | City: |  | State: |  | Zip Code: |\n| Prescribing Provider Information |  |  |  |  |  |\n| Provider Name (first & last): | Specialty: |  | NPI\\#: |  | DEA\\#: |\n| Office Address: | City: |  | State: |  | Zip Code: |\n| Office Contact: | Office Phone: |  |  | Office Fax: |  |\n| Dispensing Pharmacy Information |  |  |  |  |  |\n| Pharmacy Name: | Pharmacy Phone: |  |  | Pharmacy Fax: |  |\n| Requested Medication Information |  |  |  |  |  |\n| Medication Name: | Strength: |  |  | Dosage Form: |  |\n| Directions for Use: | Quantity: | Refills: |  | Duration of Therapy/Use: |  |\n|  Check if requesting brand only  Check if requesting generic |  |  |  |  |  |\n|  Check if requesting continuation of therapy (prior authorization approved by BCBSAZ expired) |  |  |  |  |  |\n| Turn-Around Time For Review |  |  |  |  |  |\n|  Standard  Urgent. Sign here:    Exigent (requires prescriber to include a written statement) |  |  |  |  |  |\n| Clinical Information |  |  |  |  |  |\n| 1. What is the diagnosis? Please specify below.\u003Cbr>ICD-10 Code:   Diagnosis Description:   |  |  |  |  |  |\n| 2.  Yes  No Was this medication started on a recent hospital discharge or emergency room visit? |  |  |  |  |  |\n| 3.  Yes  No There is absence of ALL contraindications. |  |  |  |  |  |\n| 4. What medication(s) has the individual tried and failed for this diagnosis? Please specify below.\u003Cbr>Important note: Samples provided by the provider are not accepted as continuation of therapy or as an adequate trial and failure.\u003Cbr>Medication Name, Strength, Frequency Dates started and stopped or Approximate Duration Describe response, reason for failure, or allergy |  |  |  |  |  |\n| 5. Are there any supporting labs or test results? Please specify below.\u003Cbr>Date Test Value |  |  |  |  |  |\n\n\n| 6. | Is there any additional information the prescribing provider feels is important to this review? Please specify below.\u003Cbr>For example, explain the negative impact on medical condition, safety issue, reason formulary agent is not suitable to a specific medical condition, expected adverse clinical outcome from use of formulary agent, or reason different dosage form or dose is needed. |\n| --- | --- |\n|  |  |\n\n\n| Signature affirms that information given on this form is true and accurate and reflects office notes |\n| --- |\n| Prescribing Provider’s Signature: Date: |\n\nPlease note: Some medications may require completion of a drug-specific request form.  \nIncomplete forms or forms without the chart notes will be returned.  \nOffice notes, labs, and medical testing relevant to the request that show medical justification are required.","cbCaid1Nd05Gf6BN","https://ap.wps.com/l/cbCaid1Nd05Gf6BN","pdf",42874,"English","# Member Information\n# Prescribing Provider Information\n# Dispensing Pharmacy Information\n# Requested Medication Information\n## Turn-Around Time For Review\n# Clinical Information\n# Signature","[{\"question\":\"What member details are required on the form?\",\"answer\":\"The form requests member name, date of birth, gender, BCBSAZ ID number, and address including city, state, and zip code.\"},{\"question\":\"Which provider and pharmacy fields must be completed?\",\"answer\":\"It requires the prescribing provider’s name, specialty, NPI, DEA, and office address and contact information, plus the dispensing pharmacy’s name and phone/fax details.\"},{\"question\":\"What clinical documentation is needed to justify the prior authorization request?\",\"answer\":\"The form asks for the diagnosis with ICD-10 code and description, confirmation of absence of contraindications, prior medication trials with response or failure reasons (including that samples are not accepted), and any supporting labs/test results, plus optional additional information from the provider.\"}]","Pharmacy Prior Authorization Request Form | PDF",1789620055]