[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288537-105":53,"doc-detail-288537-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-umwa-funds-brand-over-generic-medical-necessity","Prior Authorization Form - UMWA Funds - Brand over Generic Medical Necessity","","Prior authorization form for UMWA Funds requesting approval for coverage of Brand over Generic Medical Necessity. The form requires completion and review of HIPAA-secure information, including patient and prescribing physician details, drug selection, quantity, frequency, strength, route, and expected therapy length. It collects responses regarding renewal requests, generic re-challenge, adverse events, adequate generic trials (e.g., 30 days), MedWatch Form 3500 documentation, and FDA filing. 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Contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What medication and therapy information must be provided on the form?",{"text":113,"@type":109},"The form requires the drug name (from a list or other specification), quantity, frequency, strength, route of administration, and expected length of therapy.",{"name":115,"@type":106,"acceptedAnswer":116},"What documentation is required for benefit override consideration regarding adverse events?",{"text":117,"@type":109},"The form asks whether the adverse event was documented on MedWatch Form 3500 and whether that form was filed with the FDA, noting that MedWatch filing is required for benefit override consideration.","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},288537,1790143681,{"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":73,"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},2336478503145,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","2/2/2017  \nPrior Authorization Form  \nUMWA FUNDS  \nBrand over Generic Medical Necessity*  \nThis fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-888-487-9257. Please contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Brand over Generic Medical Necessity* .  \n\n| \u003Cbr>Drug Name (select from list of drugs shown)\u003Cbr>Other, Please specify\u003Cbr>Quantity   Frequency   Strength  \u003Cbr>Route of Administration   Expected Length of Therapy   |  |  |\n| --- | --- | --- |\n| Patient Information\u003Cbr>Patient Name:  \u003Cbr>Patient ID:  \u003Cbr>Patient Group No.:  \u003Cbr>Patient DOB:  \u003Cbr>Patient Phone: |  |  |\n| Prescribing Physician\u003Cbr>Physician Name:\u003Cbr>Physician Phone:\u003Cbr>Physician Fax:\u003Cbr>Physician Address:\u003Cbr>City, State, Zip: |  |  |\n\nDiagnosis:   ICD Code:    \nComments:    \nPlease circle the appropriate answer for each question.  \n1. Is a renewal authorization being requested for the branded Y N  \nmedication?  \n[If the answer to this question is no, then skip to question 5.]  \n2. Has the patient been re-challenged on the generic agent(s)? Y N [If the answer to this question is no, then skip to question 4.]  \n3. Did the patient experience an adverse event with the generic Y N  \nagent(s) re-challenge (e.g. , rash, nausea, vomiting)?  \n[No further questions are required.]  \n4. Does the prescriber feel the patient can safely be re-challenged Y Non the generic agent(s)?  \n[No further questions are required.]  \n5. Has the patient had a trial of the generic agent(s)? Y N  \n6. Did the patient fail an adequate trial (e.g. , 30 days) of the generic Y N agent(s)?  \n7. Was the failure due to an adverse event experienced with the Y N  \ngeneric agent(s) (e.g. , rash, nausea, vomiting)?  \n8. Is the adverse event attributable to the inactive ingredients of the Y N generic agent(s) and not the active ingredient?  \n9. Was the adverse event documented in the chart of the patient? Y N  \n10. Was the adverse event documented on the MedWatch Form Y N 3500?  \n(Note: MedWatch form can be obtained from  \n[http://www.fda.gov/downloads/Safety/MedWatch/Howtoreport/downloadforms/ucm082727.pdf or](http://www.fda.gov/downloads/Safety/MedWatch/Howtoreport/downloadforms/ucm082727.pdf or) 1- 800-FDA-1088.)  \n11. Was the MedWatch form filed with the FDA? Y N  \n(Note: Filing of the MedWatch form is required for benefit override consideration.)  \nI affirm that the information given on this form is true and accurate as of this date.  \nPrescriber (Or Authorized) Signature and Date","cbCaiuTX8oG9fdRZ","https://ap.wps.com/l/cbCaiuTX8oG9fdRZ","pdf",36480,"English","# Prior Authorization Form\n## Patient and Prescriber Information\n## Diagnosis, Drug Details, and Comments\n## Authorization Questions and Adverse Event Documentation\n## Certification Signature","[{\"question\":\"Where should the completed prior authorization form be faxed, and who can answer process questions?\",\"answer\":\"Fax signed forms to CVS/Caremark at 1-888-487-9257. Contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process.\"},{\"question\":\"What medication and therapy information must be provided on the form?\",\"answer\":\"The form requires the drug name (from a list or other specification), quantity, frequency, strength, route of administration, and expected length of therapy.\"},{\"question\":\"What documentation is required for benefit override consideration regarding adverse events?\",\"answer\":\"The form asks whether the adverse event was documented on MedWatch Form 3500 and whether that form was filed with the FDA, noting that MedWatch filing is required for benefit override consideration.\"}]","Prior Authorization Form - UMWA Funds - Brand over Generic Medical Necessity | PDF",1789633606]