[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287222-105":53,"doc-detail-287222-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-request-form-medications","Prior Authorization Request Form - Medications","","Prior Authorization Request Form - Medications collects prescriber, member, and drug-specific details required to process medication prior authorization. It includes sections for provider identifiers and contact information, member plan identifiers and date of birth, drug name and strength, dosage information, diagnosis with ICD-9 code, expected therapy duration, and refill count. The form also gathers drug history and clinical rationale, with signature and date, plus plan fax submission numbers and a revision date.",{"@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-request-form-medications/287222/",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-request-form-medications/287222.png","ImageObject",442,249,{"name":88,"@type":89},"Rowan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required in the Provider Information section?","Question",{"text":108,"@type":109},"The form requests the prescriber name, NPI number, specialty, phone and fax, and the prescriber address, plus office contact name and pharmacy name and phone.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What details must be provided in the Drug Information section?",{"text":113,"@type":109},"It requires one drug per request with drug name, strength, dosage form, dosage interval, quantity per day, diagnosis relevant to the request including an ICD-9 code, expected therapy length, and the number of refills.",{"name":115,"@type":106,"acceptedAnswer":116},"How does the form collect drug history and clinical rationale?",{"text":117,"@type":109},"It asks whether the prescription is for office administration or home use, whether the member is currently treated, whether the request continues prior approval, and whether dosing quantity changed. It also requests prior treatments and outcomes, and requires supporting clinical information with the prescriber/authorized representative signature and 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},287222,1790042001,{"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":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"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":4},1099514067415,"https://ap-avatar.wpscdn.com/avatar/100002539d78ffe74a7?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779092875211072502","Prior Authorization Request Form: Medications  \nPlease type or print neatly. Incomplete and illegible forms will delay processing.  \nI. Provider Information  \n\n| Prescriber name | NPI \\# |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Prescriber specialty | Phone |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| Prescriber address |  |  |  |  |  |  |  |  |  |  |  |\n| Office contact name | Fax |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| Pharmacy name | Pharmacy phone\u003Cbr>|  |  |  |  |  |  |  |  |  |  |\n\nII. Member Information  \n\n| Member name | Today’s date |\n| --- | --- |\n| Member plan ID \\# | Date of birth |\n| Drug allergies |  |\n| Plan name and fax for form submission\u003Cbr>Absolute Total Care 1.866.399.0929 |  |\n\nIII. Drug Information (one drug per request form)  \n\n| Drug name | Drug strength | Dosage form | Dosage interval | Quantity per day |\n| --- | --- | --- | --- | --- |\n| Diagnosis relevant to this request |  |  |  | ICD-9 code |\n| Expected length of therapy |  |  |  | Number of refills |\n\nIV. Drug History for this Diagnosis  \n\n| A. Is the prescription for a drug to be administered in the office or for the member to take at home? office home |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| B. Is the member currently treated on this drug? Yes: how long?   [go to item C] No [skip items C and D; go to item E] |  |  |  |  |\n| C. Is this request for continuation of a previous approval? Yes [go to item D] No [skip item D; go to item E] |  |  |  |  |\n| D. Has strength, dosage or quantity required per day increased or decreased?\u003Cbr>Yes [go to item E] No [skip item E; indicate rationale in Section V and submit form] |  |  |  |  |\n| E. Please indicate previous treatments and outcomes with other medications below. |  |  |  |  |\n| Drug name | Strength | Directions | Dates of therapy | Reason for failure or discontinuation |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\nV. Rationale for Request and Pertinent Clinical Information (attach additional sheets if more space is needed)  \n\n| Appropriate clinical information to support the request on the basis of medical necessity must be submitted. |  |\n| --- | --- |\n| Prescriber/Authorized Representative signature | Date |\n\nPlan Fax Numbers  \nAbsolute Total Care . . . ... . . .. . . . . 1.866.399.0929 Healthy Blue by BlueChoice of SC   1.866.807.6241 First Choice by Select Health. .. . . 1.866.610.2775 Molina Healthcare of SC   ..   1.855.571.3011 FFS Medicaid.. . . .. . .. .. . .. .. . . . . 1.888.603.7696 Wellness of SC. ... . .. .. . .. . .... . 1.866.354.8709  \nRev. 08082018","cbCaicMzBGHxJ1HU","https://ap.wps.com/l/cbCaicMzBGHxJ1HU","pdf",573212,"English","# Provider Information\n# Member Information\n# Drug Information\n# Drug History for this Diagnosis\n# Rationale for Request and Pertinent Clinical Information","[{\"question\":\"What information is required in the Provider Information section?\",\"answer\":\"The form requests the prescriber name, NPI number, specialty, phone and fax, and the prescriber address, plus office contact name and pharmacy name and phone.\"},{\"question\":\"What details must be provided in the Drug Information section?\",\"answer\":\"It requires one drug per request with drug name, strength, dosage form, dosage interval, quantity per day, diagnosis relevant to the request including an ICD-9 code, expected therapy length, and the number of refills.\"},{\"question\":\"How does the form collect drug history and clinical rationale?\",\"answer\":\"It asks whether the prescription is for office administration or home use, whether the member is currently treated, whether the request continues prior approval, and whether dosing quantity changed. It also requests prior treatments and outcomes, and requires supporting clinical information with the prescriber/authorized representative signature and date.\"}]","Prior Authorization Request Form - Medications | PDF",1789632036]