[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287451-105":53,"doc-detail-287451-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","prior-authorization-form-compounded-prescriptions","Prior Authorization Form - Compounded Prescriptions","","Prior Authorization form for compounded prescriptions, collecting required member details and prescriber information to support a PA request. Includes pharmacy information and a section for clinical criteria documentation, such as route of administration, diagnosis, availability of similar commercially available products, FDA approval status for requested use, level of effort, hands-on compounding time, equipment needs, and special considerations. Requires listing each ingredient with NDC, name, dosage form, and quantity, plus prescriber signature and office-use fields. Includes confidentiality and PHI handling instructions and submission contact details, with a response expected within 24 hours.",{"@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/prior-authorization-form-compounded-prescriptions/287451/",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/prior-authorization-form-compounded-prescriptions/287451.png","ImageObject",442,249,{"name":88,"@type":89},"Bintang","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required from the member for this prior authorization request?","Question",{"text":108,"@type":109},"The form requests member name, insurance ID, date of birth, street address, city/state/zip, and phone.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which clinical criteria must be documented for compounded prescriptions?",{"text":113,"@type":109},"It asks for the route of administration, the patient diagnosis intended to be treated, whether a similar commercially available product exists and why it is not acceptable, whether the active ingredient(s) are FDA-approved for the condition in the requested route, level of effort requested, compounding time, equipment used, and any special considerations.",{"name":115,"@type":106,"acceptedAnswer":116},"What is required to list the compounded ingredients and sign the form?",{"text":117,"@type":109},"The form requires listing the NDC, name, dosage form, and quantity of each ingredient, beginning with covered legend drugs, and attaching an additional form if there are more than 10 ingredients. It also requires the prescriber signature (and notes pharmacist signing as agent in a specified copy scenario), plus a date.","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},287451,1790457329,{"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},962085564381,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Prior Authorization Form Compounded Prescriptions  \nAccess this PA form at: [https://optumrx.com/oe _tenncare/prescriber](https://optumrx.com/oe _tenncare/prescriber)  \nIf the following information is not complete, correct, or legible, the PA process can be delayed. Use one form per member please.  \n\n| Member Information (required) |  |  | Prescriber Information (required) |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  | Provider Name: |  |  |  |\n| Insurance ID\\#: |  |  | NPI\\#: |  | DEA \\#: |  |\n| Date of Birth: |  |  | Specialty: |  |  |  |\n| Street Address: |  |  | Office Phone: |  | Office Fax: |  |\n| City: | State: | Zip: | Office Street Address: |  |  |  |\n| Phone: |  |  | City: | State: |  | Zip: |\n|  |  |  | Is the prescribera TennCare provider with a Medicaid ID? Yes No\u003Cbr>Is the prescribera single-patient contract holder for this patient? Yes No |  |  |  |\n\nPharmacy Information  \nPHARMACY NAME:     _  _  _  _  _  _  _  _  \nADDRESS:  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nCITY: STATE: ZIP CODE:  \nPHONE NUMBER:  \n\n|  |  |  |\n| --- | --- | --- |\n\n–  \n\n|  |  |  |\n| --- | --- | --- |\n\n–  \nFAX NUMBER:  \n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\n– –  \nClinical Criteria Documentation ****Do not include documentation that is not requested on this form ****  \n1. List the route of administration for the compound:  Oral  Topical  Other:   \n2. List the patient’s diagnosis which this compound is intended to treat    \n3. Is a similar commercially available product available?  Yes  No If yes, indicate why a commercially available product isnot acceptable and include the specific need for the compound; list previous failed therapies if known:  \n~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~ ~~_  \n~~ ~~ ~~ ~~_                _  \n4. Is the active ingredient(s)of the compound FDA-approved for the condition being treated in the requested route of administration?  Yes  No If no, please attach peer-reviewed medical evidence for support.  \n5. Level of Effort Requested  Level 1  Level 2  Level 3  \n6. Hands-on compounding time:  5 – 15 minutes  16 – 30 minutes  Over 30 minutes  \n Laminar flow hood  Unguator  Homogenizer  N/A (or if other, explain in  \n7. Special equipment used: comments)  \n8. Special considerations:  Complex formulation  Sterility Testing  N/A (or if other, explain in comments)  \n9. Additional Information:    \nThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider named above is required to safeguard PHI by applicable law. The information in this document is forthe sole use of OptumRx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing , copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately.  \nOffice use only: CompoundedPrescriptions_TennCare_ 2020Jan Revision Date: 10/11/2019  \nPrior Authorization Form Compounded Prescriptions  \nList the NDC, name, dosage form, and qty of each ingredient. Each ingredient used in the compound MUST be listed. Begin the list with the covered legend drugs. Please attach an additional form if compound has greater than 10 ingredients.  \nRx Required  \nActive Ingredient  \nBase/ Vehicle  \nExcipient /Other  \nPrescriber Signature (Required)  \n(By signature, the Prescriber confirms the above information is accurate and verifiable by patient records.)  \n(Note: Pharmacist may sign as agent of PrescriberIF copy o","cbCaiqeoAJda1DId","https://ap.wps.com/l/cbCaiqeoAJda1DId","pdf",349304,"English","# Member Information (Required)\n# Prescriber Information (Required)\n# Pharmacy Information\n# Clinical Criteria Documentation\n# Ingredient Listing and Signature\n# Submission and Confidentiality Notice","[{\"question\":\"What information is required from the member for this prior authorization request?\",\"answer\":\"The form requests member name, insurance ID, date of birth, street address, city/state/zip, and phone.\"},{\"question\":\"Which clinical criteria must be documented for compounded prescriptions?\",\"answer\":\"It asks for the route of administration, the patient diagnosis intended to be treated, whether a similar commercially available product exists and why it is not acceptable, whether the active ingredient(s) are FDA-approved for the condition in the requested route, level of effort requested, compounding time, equipment used, and any special considerations.\"},{\"question\":\"What is required to list the compounded ingredients and sign the form?\",\"answer\":\"The form requires listing the NDC, name, dosage form, and quantity of each ingredient, beginning with covered legend drugs, and attaching an additional form if there are more than 10 ingredients. It also requires the prescriber signature (and notes pharmacist signing as agent in a specified copy scenario), plus a date.\"}]","Prior Authorization Form - Compounded Prescriptions | PDF",1789632343]