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Supporting clinical rationale and required documentation help ensure medical-necessity review and prevent delays.",{"@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/prior-authorization-request-form-for-prescription-drugs-complete-and-submit/283859/",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/prior-authorization-request-form-for-prescription-drugs-complete-and-submit/283859.png","ImageObject",442,249,{"name":42,"@type":43},"Putri","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-02","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must be provided to submit a prior authorization request?","Question",{"text":63,"@type":64},"The form requires member name, identification number, drug name, prescriber and provider contact information, and diagnosis-related details. Incomplete forms delay processing.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Can I request more than one drug using this form?",{"text":68,"@type":64},"No. The document states that it is one drug request per form.",{"name":70,"@type":61,"acceptedAnswer":71},"How is medication history used in the authorization decision?",{"text":72,"@type":64},"The form asks whether the member is currently treated on the medication, whether it is a continuation of a previous approval, and whether strength, dosage, or quantity has changed. It also requests prior treatment and outcomes.","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},283859,1790007900,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},962085571259,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","PRIOR AUTHORIZATION REQUEST FORM FOR PRESCRIPTION DRUGS FAX this completed form to (800) 977-4170  \nOR Complete Electronically at [https://www.covermymeds.com/main/prior-authorization-forms/](https://www.covermymeds.com/main/prior-authorization-forms/)  \n[OR Mail requests to: Pharmacy Services PA Dept. | 5 River Park Place East](OR Mail requests to: Pharmacy Services PA Dept. | 5 River Park Place East), Suite 210 | Fresno, CA 93720  \n| I. Provider Information |  |  |  | II. Member Information |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Prescriber name (print): |  |  |  | Member name: |  |  |\n| Office contact name: |  |  |  | Identification number: |  |  |\n| Group name: |  |  |  | Group number: |  |  |\n| Fax: |  |  |  | Date ofBirth: |  |  |\n| Phone: |  |  |  | Medication allergies: |  |  |\n| III. Drug Information (One drug request per form) |  |  |  |  |  |  |\n| Drug name and strength: |  | Dosage form: |  | Dosage Interval (sig): | Qty per Day: |  |\n| Diagnosis relevant to this request: |  |  |  |  |  |  |\n| Expected length of therapy: |  |  |  |  |  |  |\n| Medication History for this Diagnosis |  |  |  |  |  |  |\n| A. Is member currently treated on this medication?\u003Cbr>yes; How Long?  [go to item B]  no [skip items B & C; go to item D] |  |  |  |  |  |  |\n| B. Is this request for continuation of a previous approval?\u003Cbr>yes [go to item C]  no [skip item C; go to item D] |  |  |  |  |  |  |\n| C. Has strength, dosage, or quantity required per day increased or decreased?\u003Cbr>yes [go to item D]  no [skip item D; indicate rationale for continuation in Section IV and submitform] |  |  |  |  |  |  |\n| D. Please indicate previous treatment and outcomes below. |  |  |  |  |  |  |\n| Drug Name\u003Cbr>(include strength and dosage) | Dates of Therapy |  | Reason for Discontinuation |  |  |  |\n| 1 |  |  |  |  |  |  |\n| 2 |  |  |  |  |  |  |\n| 3 |  |  |  |  |  |  |\n| 4 |  |  |  |  |  |  |\n| NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Ambetter Formulary is available on the Ambetter Health website [at](at www.ambetterhealth.com)[ www.ambetterhealth.com](at www.ambetterhealth.com) (search for your state to view your specific formulary document.) |  |  |  |  |  |  |\n| IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations) |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| Appropriate clinical information to support the request on the basis of medical necessity must besubmitted. |  | Provider Signature: |  |  | Date: |  |\n\nPharmacy Services and Ambetter Health will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends or holidays. Requests for prior authorization (PA) requests must include member name, ID\\#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.)","cbCaiolM9UcYwqrq","https://ap.wps.com/l/cbCaiolM9UcYwqrq","pdf",1902775,"English","# Provider Information\n# Member Information\n# Drug Information\n## Medication History for this Diagnosis\n# Rationale for Request / Pertinent Clinical Information\n## Submission and Required Documents","[{\"question\":\"What information must be provided to submit a prior authorization request?\",\"answer\":\"The form requires member name, identification number, drug name, prescriber and provider contact information, and diagnosis-related details. Incomplete forms delay processing.\"},{\"question\":\"Can I request more than one drug using this form?\",\"answer\":\"No. The document states that it is one drug request per form.\"},{\"question\":\"How is medication history used in the authorization decision?\",\"answer\":\"The form asks whether the member is currently treated on the medication, whether it is a continuation of a previous approval, and whether strength, dosage, or quantity has changed. It also requests prior treatment and outcomes.\"}]","Prior Authorization Request Form for Prescription Drugs - Complete and Submit | PDF",1789620950]