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Providers are encouraged to submit the form and chart documentation through the Health Alliance Pharmacy Provider Portal for more reliable communication and expedited determination notifications. If portal access is unavailable, the form and documentation may be faxed. The form collects member details, request type, hospitalization status, requesting provider information, and facility details for provider-administered drugs, plus urgent definitions and required clinical, formulary exception, and prior treatment information.",{"@graph":63,"@context":119},[64,80,102],{"@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/pharmacymedical-drug-prior-authorization-form-request-coverage-for-all-drugs/283761/",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/pharmacymedical-drug-prior-authorization-form-request-coverage-for-all-drugs/283761.png","ImageObject",442,249,{"name":88,"@type":89},"Sarah ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"When should this Pharmacy/Medical Drug Prior Authorization form be used?","Question",{"text":109,"@type":110},"Use it to request coverage for drugs under either the pharmacy or medical benefit, including when submitting supporting chart documentation.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What does “urgent” mean on this form?",{"text":114,"@type":110},"Urgent refers to care where using the standard non-urgent timeline could seriously jeopardize the patient’s life or health, impair the ability to regain maximum function, or cause severe pain that cannot be managed adequately without the requested care.",{"name":116,"@type":107,"acceptedAnswer":117},"What information is required for formulary exception requests?",{"text":118,"@type":110},"The form asks whether the request is for specific exception types (non-formulary, quantity, tiering, step-therapy, or prior authorization exceptions) and requires a supporting statement and chart documentation.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283761,1790395911,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962085320529,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Pharmacy/Medical Drug Prior Authorization Form  \nImportant: Use this form when requesting coverage for all drugs covered under either the pharmacy or medical benefit. Providers are strongly encouraged to submit this form and all chart documentation via the Health Alliance Pharmacy Provider Portal. This will result in more reliable communication and expedited notification of determinations. Alternatively, if you are  \nunable to access the portal, fax this form and all chart documentation to (217) 902-9798. If you have questions, please call  \n(800) 851-3379.  \no Urgent means medical care or treatment where using the timetable for a non-urgent care determination could seriously jeopardize the patient's life/health, or the patient's ability to regain maximum function or in the opinion of the attending or consulting physician, would subject the patient to severe pain that could not be adequately managed without the requested care or treatment.  \n\n| Section A-Member Information |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Today's Date: |  | First Name: |  |  |  |  |  |  | Last Name: |  |\n| Member ID \\#: |  | Date of Birth: |  |  |  |  | Primary Insurance: |  |  |  |\n| Is this a o new request or o a continuation of therapy or o a retrospective request for payment? Start date   Were manufacturer samples provided? o Yes o No If yes, quantity/days of supply  \u003Cbr>Are the drugs being requested as part of a clinical trial? o Yes o No If yes, list the clinical trial NCT\\# or FDA issued IND\\#:   Is this patient currently hospitalized? o Yes o No If yes, include the anticipated discharge date   |  |  |  |  |  |  |  |  |  |  |\n| Section B-Requesting Provider Information |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  |  | Last Name: |  |  |  |  |  |  |\n| Address: |  |  |  | City: |  |  |  |  | State: | Zip code: |\n| Phone: |  | Fax: |  |  |  |  |  |  | NPI: |  |\n| Specialty: |  | Email: |  |  |  |  |  |  | Contact Name: |  |\n| Participating provider? o Yes o No If no, do you have an approval to consult and treat? oYes o No Auth \\# |  |  |  |  |  |  |  |  |  |  |\n| Section C- Information for Drugs that are Administered by Provider (not Self-Administered) |  |  |  |  |  |  |  |  |  |  |\n| Are any of these drugs medical service drugs? o Yes o No If yes, please answer the next question |  |  |  |  |  |  |  |  |  |  |\n| The medical service drug(s) will be administered at what type of facility? o home infusion/long-term care o infusion suite/expanded care |  |  |  |  |  |  |  |  |  |  |\n| Is the rendering provider information the same as Section B? o Yes o No If no, you must complete the rest of this section |  |  |  |  |  |  |  |  |  |  |\n| Facility/Provider Name: |  |  |  |  |  |  |  |  |  |  |\n| Address: |  |  |  | City: |  |  |  |  | State: | Zip code: |\n| Phone: |  | Fax: |  |  |  |  |  |  | NPI: |  |\n| Participating facility/provider? o Yes o No If no, do you have an approval to consult and treat? o Yes o No Auth \\#  |  |  |  |  |  |  |  |  |  |  |\n| Section D-Drug Formulary Exception Requests ***Please include a supporting statement and chart documentation*** |  |  |  |  |  |  |  |  |  |  |\n| Is this a request for any of the following exceptions to any formulary design? o Yes* o No\u003Cbr>o Non-formulary Exception-Coverage of a drug not currently listed on the formulary.\u003Cbr>o Quantity Exception-Coverage of a quantity of drug greater than the formulary limit.\u003Cbr>o Tiering Exception-Reduce the tier of a formulary drug (Specialty drugs are exempt) .\u003Cbr>o Step-Therapy Exception-Request to bypass step therapy requirements.\u003Cbr>o Prior Authorization Exception-The drug-specific prior authorization criteria should not apply to your patient. |  |  |  |  |  |  |  |  |  |  |\n| Section E-clinical Information of Drug(s) Requested ***Please include chart documentation*** |  |  |  |  |  |  |  |  |  |  |\n| Drug Name & Strength | HCPCS |  | Qty/Days |  |  | Dose Per Administration/Directions for Use/Fre","cbCaipAwXhzuVkfL","https://ap.wps.com/l/cbCaipAwXhzuVkfL","pdf",1873701,"English","# Pharmacy/Medical Drug Prior Authorization Form\n## Member Information\n## Requesting Provider Information\n## Provider-Administered Drug Information\n## Drug Formulary Exception Requests\n## Clinical Information of Requested Drug(s)\n## Previous Treatments\n## Certification and Signature","[{\"question\":\"When should this Pharmacy/Medical Drug Prior Authorization form be used?\",\"answer\":\"Use it to request coverage for drugs under either the pharmacy or medical benefit, including when submitting supporting chart documentation.\"},{\"question\":\"What does “urgent” mean on this form?\",\"answer\":\"Urgent refers to care where using the standard non-urgent timeline could seriously jeopardize the patient’s life or health, impair the ability to regain maximum function, or cause severe pain that cannot be managed adequately without the requested care.\"},{\"question\":\"What information is required for formulary exception requests?\",\"answer\":\"The form asks whether the request is for specific exception types (non-formulary, quantity, tiering, step-therapy, or prior authorization exceptions) and requires a supporting statement and chart documentation.\"}]","Pharmacy/Medical Drug Prior Authorization Form - Request Coverage for All Drugs | PDF",1789618854]