[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288196-105":53,"doc-detail-288196-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","prescription-drug-medication-request-form-fax","Prescription Drug Medication Request Form - Fax","","Prescription Drug Medication Request Form used to request coverage and additional quantities for medications, including patient information, clinical and medication details, diagnosis, transplant history, alternatives tried, and medical rationale. Requires prescribing physician information such as name, NPI or Tax ID, address, and signature, and selection of Medicare commercial request type (tiering exception, non-formulary, prior authorization; standard/peer-to-peer/expedited appeals). Includes completion instructions, fax or mail submission details, and guidance on documentation requirements for non-formulary, prior authorization, and MRXC managed prescription drug coverage.",{"@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/prescription-drug-medication-request-form-fax/288196/",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/prescription-drug-medication-request-form-fax/288196.png","ImageObject",442,249,{"name":88,"@type":89},"Theodore","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be completed on the form?","Question",{"text":108,"@type":109},"The form requires patient details, clinical and medication information (drug name, strength/dose, requested quantity, diagnosis), alternatives tried, and the medical rationale. It also requires physician information and selection of the Medicare request type.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should the completed form be submitted?",{"text":113,"@type":109},"Fax the completed form to 1-866-240-8123, or mail it to Medical Management & Policy at 120 Fifth Avenue, MC P4207, Pittsburgh, PA 15222.",{"name":115,"@type":106,"acceptedAnswer":116},"What documentation is generally needed for non-formulary and prior authorization requests?",{"text":117,"@type":109},"For non-formulary, documentation of a trial of at least two formulary products is required in most cases. For prior authorization, the form references common drug categories and specifies that required documentation depends on the therapy and criteria.","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},288196,1790172847,{"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":47,"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},7971461740886,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","PRESCRIPTION DRUG MEDICATION REQUEST FORM FAX TO 1-866-240-8123  \n[http://highmark.formularies.com](http://highmark.formularies.com) [http://highmark.medicare-approvedformularies.com](http://highmark.medicare-approvedformularies.com)  \nTo view our formularies on-line, please visit our Web site at the addresses listed above.  \nFax each form separately. Please use a separate form for each drug.  \nPrint, type or write legibly in blue or black ink. See reverse side for additional details  \n\n| PATIENT INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Subscriber ID Number |  |  | Highmark Coverage\u003Cbr>n MA-PD n PDP |  |  |  |  |  | Group Number |  |  |  |  |  |  |\n| Patient Name |  |  |  |  |  | Patient Telephone Number |  |  |  |  |  |  | Date of Birth |  |  |\n| Patient Address |  |  |  |  |  | City |  |  |  |  |  |  | State |  | Zip Code |\n| CLINICAL / MEDICATION INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Drug Name |  |  |  |  |  | Strength or Dose |  |  |  |  |  | Requested Quantity per Month |  |  |  |\n| Diagnosis |  |  |  |  |  |  |  | Name of the Carrier who paid for Most Recent Transplant |  |  |  |  |  |  |  |\n| Type of Transplant\u003Cbr>n Lung n Heart n Kidney n GVH\u003Cbr>n Other   |  |  |  |  |  | Date of Most Recent Transplant |  |  |  |  |  | Most Recent Transplant Payer (check one)\u003Cbr>n Commercial\u003Cbr>n Medicare Advantage\u003Cbr>n Medicare FFS |  |  |  |\n| Alternatives Tried / Used By Patient (if applicable) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Drug Name |  | Strength |  |  | Documentation of Failure of Therapy |  |  |  |  |  |  |  |  |  |  |\n| Drug Name |  | Strength |  |  | Documentation of Failure of Therapy |  |  |  |  |  |  |  |  |  |  |\n| Drug Name |  | Strength |  |  | Documentation of Failure of Therapy |  |  |  |  |  |  |  |  |  |  |\n| Medical Rationale / Reason for Drug Therapy / Treatment Plan |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| PHYSICIAN INFORMATION (needed for mailing notification-please print legibly) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Physician Name |  |  |  | NPI or Tax ID \\# (Required) |  |  |  |  |  | Phone |  |  |  | Fax |  |\n| Physician Address |  |  |  |  |  | City |  |  |  |  | State |  |  | Zip Code |  |\n| Suite / Building |  |  |  | Physician Signature |  |  |  |  |  |  |  |  |  | Date |  |\n| MEDICARE COMMERCIAL REQUEST TYPE |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| n Tiering Exception\u003Cbr>n Non-Formulary\u003Cbr>n Prior Authorization | n Non-Formulary\u003Cbr>n Prior Authorization |  |  |  |  |  | n Standard Request n Peer to Peer\u003Cbr>n Expedited Request n Expedited Appeal\u003Cbr>n Standard Appeal |  |  |  |  |  |  |  |  |\n\nOnce a clinical decision has been made, a decision letter will be mailed to the patient and physician.  \nFor other helpful information, please visit the Highmark Web site at:  \n[www.highmark.com](www.highmark.com)  \nNS_ 12_0133  \nMM-056 (R11-13)  \nINSTRUCTIONS FOR COMPLETING THE FORM  \n1. Submit a separate form for each medication.  \n2. Complete ALL information on the form.  \nNOTE: The prescribing physician (PCP or Specialist) should, in most cases, complete the form.  \n3. Please provide the physician address as it is required for physician notification.  \n4. Fax the completed form to 1-866-240-8123  \nOr mail the form to: Medical Management & Policy  \n120 Fifth Avenue, MC P4207, Pittsburgh, PA 15222  \nCLINICAL MANAGEMENT PROCEDURES  \nIn general, when requesting coverage for a medication, the following information in the bullet points below is required:  \nNON-FORMULARY  \n• Most products: documentation of a trial of at least two formulary products  \nPRIOR AUTHORIZATION  \nBelow is a list of common drugs and/or therapeutic categories that require prior authorization:  \n• Agents used for fibromyalgia (e.g. Cymbalta, Lyrica, Savella)  \n• Test","cbCais1SqITciG7m","https://ap.wps.com/l/cbCais1SqITciG7m","pdf",75749,"English","# Patient Information\n# Clinical / Medication Information\n# Physician Information\n# Medicare Commercial Request Type\n# Instructions for Completing the Form\n## Fax/Mail Submission\n## Clinical Management Procedures","[{\"question\":\"What information must be completed on the form?\",\"answer\":\"The form requires patient details, clinical and medication information (drug name, strength/dose, requested quantity, diagnosis), alternatives tried, and the medical rationale. It also requires physician information and selection of the Medicare request type.\"},{\"question\":\"How should the completed form be submitted?\",\"answer\":\"Fax the completed form to 1-866-240-8123, or mail it to Medical Management \\u0026 Policy at 120 Fifth Avenue, MC P4207, Pittsburgh, PA 15222.\"},{\"question\":\"What documentation is generally needed for non-formulary and prior authorization requests?\",\"answer\":\"For non-formulary, documentation of a trial of at least two formulary products is required in most cases. For prior authorization, the form references common drug categories and specifies that required documentation depends on the therapy and criteria.\"}]","Prescription Drug Medication Request Form - Fax | PDF",1789633223]