[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287309-105":53,"doc-detail-287309-en":131},{"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":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","prescription-drug-prior-authorization-pa-request-form-2018","Prescription Drug Prior Authorization - PA Request Form - 2018","","Outpatient medication prior authorization and step-therapy exception request form for pharmacy-dispensed drugs, including submission instructions, required supporting clinical documentation, and guidance on using formulary alternatives before requesting PA. Provides date-based requirements for the specific DMHC-mandated state-wide PA request form, states that requests on older forms will be denied, and outlines tips for improving approval chances. Includes detailed patient, prescriber, insurance, and medication fields plus submission contacts for the Alliance Pharmacy Benefits Manager and PerformRx.",{"@graph":63,"@context":123},[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/prescription-drug-prior-authorization-pa-request-form-2018/287309/",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-prior-authorization-pa-request-form-2018/287309.png","ImageObject",442,249,{"name":88,"@type":89},"Emma Mercer","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-27","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"Who should use this prior authorization form?","Question",{"text":109,"@type":110},"Use it for outpatient drugs dispensed from a retail or specialty pharmacy. Physician-administered drugs (buy and bill) should use the separate medical management PA request form.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What documentation must be submitted with the request?",{"text":114,"@type":110},"Submit the completed form and all relevant supporting information, such as chart notes or lab data. Include clinic notes and lab values, and provide therapy dates and outcomes for other medications tried.",{"name":116,"@type":107,"acceptedAnswer":117},"Why might a PA request be denied?",{"text":118,"@type":110},"Requests made on an old Alliance PA request form or any other non-required form will be denied until resubmitted on the required form (Form 61-211, revised 12/16).",{"name":120,"@type":107,"acceptedAnswer":121},"What is included in the form’s required information fields?",{"text":122,"@type":110},"The form collects patient demographics, authorized representative details (if applicable), insurance information, prescriber information, and medication/dispensing specifics including dose, frequency, administration route, and therapy or renewal details.","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},287309,1790179882,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":144,"read_time":9},962084925502,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","OUTPATIENT MEDICATION PRIOR AUTHORIZATION REQUEST FORM  \nINSTRUCTIONS:  \n1. Complete the attached PA request form. All fields must be completed.  \n2. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request.  \n3. Submit the completed form and supporting information to the Alliance Pharmacy Benefits Manager (PBM), PerformRx at 855.811.9329.  \nNOTE: This form is only used for drugs dispensed from a retail or specialty pharmacy.  \nFor Physician Administered Drugs (i.e.,“buy and bill”) and associated procedure codes, please use the Alameda Alliance for Health (Alliance) Medical Management Prior Authorization (PA) request form, found on the Alliance [website:](website: www.alamedaalliance.org/providers/resources/forms)[ ](website: www.alamedaalliance.org/providers/resources/forms)[www.alamedaalliance.org/providers/resources/forms](website: www.alamedaalliance.org/providers/resources/forms).  \nSUMMARY:  \nAs of Tuesday, January 1, 2018, the Alliance will ONLY accept the Department of Managed Health Care (DMHC) mandated state‐wide PA request form 61-211 (revised 12/16) for drugs dispensed from a pharmacy which can be found on the attached page and online at the Alliance website:  \n[www.alamedaalliance.org/providers/pharmacy-drug-benefits](www.alamedaalliance.org/providers/pharmacy-drug-benefits. This)[. This](www.alamedaalliance.org/providers/pharmacy-drug-benefits. This) requirement is in accordance with California Health & Safety Code § 1367. 241, §1368, and §1368 .01 and §10123 .191 of the California Insurance Code.  \nRequests made on an old Alliance PA request form or any other form (including the Medi‐Cal TAR request form) will be denied until it is resubmitted on the required form (Form 61‐211, revised 12/16) .  \nTIPS FOR SUBMITTING SUCCESSFUL PA REQUESTS:  \n􀁸 Fill out all fields on the PA form. BOTH sides of this two (2) page form must be submitted.  \n􀁸 Submit all relevant clinic notes, consultations, and lab values. The more understanding we have of the clinical situation, the better the chances for approval.  \n􀁸 Use formulary alternatives (which can be found using the Formulary Lookup Tool at [www.alamedaalliance.org/members/pharmacy-and-drug-benefits](www.alamedaalliance.org/members/pharmacy-and-drug-benefits)) before submitting a PA Request. For other medications tried, submit dates of therapy and therapeutic outcomes. We strongly encourage you to also attach clinic or progress notes documenting use of alternative agents.  \nPRIOR AUTHORIZATION RESOURCES:  \n\n| RESOURCE | PHONE NUMBER |\n| --- | --- |\n| Fax number where completed PA forms should be sent | 855.811.9329 |\n| Phone number for the Alliance Pharmacy Department | 510.747.4541 |\n| Phone number for PerformRx Pharmacy Help Desk | 855.508.1713 |\n\nPRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM  \nPlan/Medical Group Name:   Plan/Medical Group Phone\\#: (  )  Plan/Medical Group Fax\\#: (  )  Non-Urgent  Exigent Circumstances   \n\n| Instructions: Please fill out all applicable sections on both 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 or step-therapy exception request. Information contained in this form is Protected Health Information under HIPAA. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  | Last Name: |  |  |  |  | MI: |  |  | Phone Number: |  |  |  |  |\n| Address: |  |  |  |  | City: |  |  |  |  |  |  | State: |  |  | Zip Code: |\n| Date of Birth: |  Male\u003Cbr> Female |  |  | Circle unit of measure\u003Cbr>Height (in/cm):  Weight (lb/kg):  |  |  |  |  | Allergies: |  |  |  |  |  |  |\n| Patient’s Authorized Representative (if applicable): |  |  |  |  |  |  | Autho","cbCainFKHBDgOFhb","https://ap.wps.com/l/cbCainFKHBDgOFhb","pdf",421547,"English","# Instructions\n## Submission requirements and contacts\n# Patient information\n# Prescriber information\n# Insurance information\n# Medication and dispensing information\n## Therapy type and administration details","[{\"question\":\"Who should use this prior authorization form?\",\"answer\":\"Use it for outpatient drugs dispensed from a retail or specialty pharmacy. Physician-administered drugs (buy and bill) should use the separate medical management PA request form.\"},{\"question\":\"What documentation must be submitted with the request?\",\"answer\":\"Submit the completed form and all relevant supporting information, such as chart notes or lab data. Include clinic notes and lab values, and provide therapy dates and outcomes for other medications tried.\"},{\"question\":\"Why might a PA request be denied?\",\"answer\":\"Requests made on an old Alliance PA request form or any other non-required form will be denied until resubmitted on the required form (Form 61-211, revised 12/16).\"},{\"question\":\"What is included in the form’s required information fields?\",\"answer\":\"The form collects patient demographics, authorized representative details (if applicable), insurance information, prescriber information, and medication/dispensing specifics including dose, frequency, administration route, and therapy or renewal details.\"}]","Prescription Drug Prior Authorization - PA Request Form - 2018 | PDF",1789632141]