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The form requires clinical rationale and pertinent information to support medical necessity, includes provider signature and date, and specifies submission by fax or mail with response within 24 hours after complete information.",{"@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-coverage-request-submission-details/283849/",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-coverage-request-submission-details/283849.png","ImageObject",442,249,{"name":42,"@type":43},"Angel","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",14,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How should this prior authorization request form be submitted?","Question",{"text":63,"@type":64},"Send the completed form by fax or mail to the Envolve Pharmacy Solutions PA Department. Fax is directed to 1.866.399.0929, and mail address is provided in the instructions.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information is required for the drug request section?",{"text":68,"@type":64},"Provide drug name and strength, dosage form, dosage interval (sig), quantity per day, diagnosis relevant to the request, and expected length of therapy. Include one drug request per form.",{"name":70,"@type":61,"acceptedAnswer":71},"What is needed in the rationale section to support the request?",{"text":72,"@type":64},"Appropriate clinical information supporting medical necessity must be submitted for all prior authorizations. The provider must sign and include the date.","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},283849,1790228689,{"code":4,"msg":82,"data":83},"success",[84,89,94,98,103,108,112,117,122],{"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":55,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},687207412472,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Prior Authorization Request Form for Prescription Drugs  \nCoverMyMeds is Envolve Pharmacy Solutions’ preferred way to receive prior authorization [requests. Visit](requests. Visit CoverMyMeds.com/EPA/EnvolveRx to begin using this free service)[ CoverMyMeds.com/EPA/EnvolveRx](requests. Visit CoverMyMeds.com/EPA/EnvolveRx to begin using this free service)[ to begin using this free service](requests. Visit CoverMyMeds.com/EPA/EnvolveRx to begin using this free service).  \nOR FAX this completed form to 1.866.399.0929  \nOR Mail requests to: Envolve Pharmacy Solutions PA Department | 5 River Park Place East, Suite 210 | Fresno, CA 93720  \n\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 of Birth: |  |  |  |\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 submit form] |  |  |  |  |  |  |\n| D. Please indicate previous treatment and outcomes below. |  |  |  |  |  |  |\n| Drug Name (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 Envolve Pharmacy Solutions Formulary is available on the Envolve Pharmacy Solutions website at [EnvolveRx.com](EnvolveRx.com) (access from Members Section of homepage, then click on Searchable Formulary/Envolve Pharmacy Solutions) . |  |  |  |  |  |  |\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 be submitted. |  |  | Provider Signature: |  |  | Date: |\n\nEnvolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information.  \nRequests for prior authorization (PA) must include member name and ID\\#, and drug name. Incomplete forms will delay processing.  \nPlease include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.)","cbCaiaApTgi9UYND","https://ap.wps.com/l/cbCaiaApTgi9UYND","pdf",482986,"English","# Provider Information\n# Member Information\n# Drug Information\n## Medication History\n# Rationale for Request / Pertinent Clinical Information","[{\"question\":\"How should this prior authorization request form be submitted?\",\"answer\":\"Send the completed form by fax or mail to the Envolve Pharmacy Solutions PA Department. Fax is directed to 1.866.399.0929, and mail address is provided in the instructions.\"},{\"question\":\"What information is required for the drug request section?\",\"answer\":\"Provide drug name and strength, dosage form, dosage interval (sig), quantity per day, diagnosis relevant to the request, and expected length of therapy. Include one drug request per form.\"},{\"question\":\"What is needed in the rationale section to support the request?\",\"answer\":\"Appropriate clinical information supporting medical necessity must be submitted for all prior authorizations. The provider must sign and include the date.\"}]","Prior Authorization Request Form for Prescription Drugs - Coverage request submission details | PDF",1789620892]