[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283900-105":3,"doc-detail-283900-en":81,"detail-sidebar-cat-1-en-105":97},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","prescription-drug-prior-authorization-form-general","Prescription Drug Prior Authorization Form - General","","Prescription Drug Prior Authorization Form collects complete member, prescriber, and medication details to support coverage determinations by the health plan or insurer. The form captures request urgency, drug characteristics (name, form, strength, dosing, therapy length, quantity, refills, and day supply), dispensing and administration information, and related diagnosis and ICD-10 codes. It also gathers prior therapies, clinical rationale, attachments as needed for review, and an attestation with prescriber signature for audit-ready accuracy.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/prescription-drug-prior-authorization-form-general/283900/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/prescription-drug-prior-authorization-form-general/283900.png","ImageObject",442,249,{"name":42,"@type":43},"Olivia Brown","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",15,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required from the member and prescriber?","Question",{"text":63,"@type":64},"The form requests member identity and demographics, plus prescriber contact details and identifiers such as NPI and DEA number. It also includes specialty and full addresses for both parties where applicable.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which drug details must be provided for the prior authorization request?",{"text":68,"@type":64},"Required fields include drug name, form, strength, dosing frequency, length of therapy, quantity, number of refills, day supply, and whether it is a new therapy or renewal with dates.",{"name":70,"@type":61,"acceptedAnswer":71},"What supporting clinical information and attachments are expected?",{"text":72,"@type":64},"Submit prior medication attempts, duration of therapy with dates, response or reason for failure/allergy, diagnoses with ICD-10 codes, and any additional clinical data supporting initial or ongoing therapy and increased dosing. Include chart notes or lab data when needed, and provide required justification for any exigent circumstances or applicable state and federal law requirements.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283900,1790176158,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":92,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":93,"faqs":94,"seo_title":95,"seo_description":12,"update_tm":96,"read_time":22},16904993612988,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd",17,"Prescription Drug Prior Authorization Form  \nFax this form to 1-800-424-3260 A fax cover sheet is not required.  \nPrime Therapeutics partners with CoverMyMeds to allow for the submission of electronic PA requests. For faster coverage determinations, [go to](go to www.CoverMyMeds.com)[ ](go to www.CoverMyMeds.com)[www.CoverMyMeds.com](go to www.CoverMyMeds.com).  \nPlease fill out all applicable sections on all pages completely and legibly. Attach any additional documentation that is important for the review (e.g. , chart notes or lab data, to support the prior authorization) . Information contained in this form is Protected Health Information under HIPAA.  \nDate of Request:    Non-Urgent  Exigent Circumstances  \nMEMBER INFORMATION  \nMember’s Last Name:   Member’s First Name:   Member’s ID:  Date of Birth: Member’s Phone:   \nMember’s Street Address:   City:  State: Zip:  Sex:  Male  Female Height:   in.  cm Weight:   lbs.  kg  \nAllergies:    \nIf you are not the member or prescriber, please submit a PHI Disclosure Authorization form with this request, located [at](at Primetherapeutics.com/patientforms)[ ](at Primetherapeutics.com/patientforms)[Primetherapeutics.com/patientforms](at Primetherapeutics.com/patientforms).  \nPRESCRIBER INFORMATION  \nPrescriber’s Last Name:   Prescriber’s First Name:   Specialty:  Email:  Prescriber’s NPI:  DEA \\#:  Prescriber’s Phone:  Prescriber’s Fax:  Prescriber’s Street Address:   City:  State: Zip:   \nDRUG INFORMATION  \nDrug Name:  Drug Form:  Drug Strength:  Dosing Frequency:  Length of Therapy:  Quantity:  Number of Refills:  Day Supply:   New Therapy  Renewal If renewal, date therapy initiated:   If renewal, duration of therapy (specific dates):  to   \nRevision Date: 01/30/2023 Commercial Clients  \n© 2017–2024 Prime Therapeutics Management LLC, a Prime Therapeutics LLC company. Page 1 of 3  \nMember’s Full Name:    \nDISPENSING INFORMATION  \nHow did the member receive the medication?  \n Paid Under Insurance  \nPrior Authorization \\# (if known):   Insurance Name:  \n Other (explain):  \nAdministration:  \nOral/SL  Topical  Injection  IV  Other:    \nAdministration Location:  \n Member’s Home  Long-Term Care  Physician’s Office  \n Home Care Agency  Ambulatory Infusion Center  Outpatient Hospital Care  \n Other (explain):    \nDIAGNOSIS AND MEDICAL INFORMATION  \n1. Has the member tried any other medications for this condition?  \n Yes  No  \na. If Yes , what was the medication therapy (specify drug name and dosage)?  \nb. What was the duration of therapy? Specify dates:  to   \nc. What was the response, reason for failure, or allergy?  \n2. What are the member’s diagnoses and ICD-10 codes?  \nDiagnoses:   ICD-10 codes:    \nPrescription Drug Prior Authorization Form: General Page 2 of 3  \nMember’s Full Name:    \n3. What additional clinical information do you have that is relevant to this request for a prior  \nauthorization? Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if the member has any contraindications for the health plan/insurer preferred drug. Lab results with dates must be provided if needed to establish diagnosis or evaluate response. Please provide any additional clinical information or comments pertinent to this request for coverage, including information related to exigent circumstances, or required under state and federal laws.  \n Attachments  \nAttestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group, or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.  \nPrescriber’s Signature:  Date: (By signature, the physician confirms the above information is accurate and verifiable by patient records.)  \nMail requests to:  \nPrime Therapeutics Management LLC  \nAttn: CP – 4201  \nP. O. Box 64811  \nSt. Paul, MN 55164-0811  \nPhone: 1-800-424-3","cbCaik4DeuyxXzNb","https://ap.wps.com/l/cbCaik4DeuyxXzNb","pdf",658627,"English","# Member information\n## Prescriber information\n## Drug information\n## Dispensing information\n## Diagnosis and medical information\n## Attachments and attestation","[{\"question\":\"What information is required from the member and prescriber?\",\"answer\":\"The form requests member identity and demographics, plus prescriber contact details and identifiers such as NPI and DEA number. It also includes specialty and full addresses for both parties where applicable.\"},{\"question\":\"Which drug details must be provided for the prior authorization request?\",\"answer\":\"Required fields include drug name, form, strength, dosing frequency, length of therapy, quantity, number of refills, day supply, and whether it is a new therapy or renewal with dates.\"},{\"question\":\"What supporting clinical information and attachments are expected?\",\"answer\":\"Submit prior medication attempts, duration of therapy with dates, response or reason for failure/allergy, diagnoses with ICD-10 codes, and any additional clinical data supporting initial or ongoing therapy and increased dosing. 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