[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288939-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-288939-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","skyrizi-medicare-prior-authorization-request-form-prior-authorization-request","Skyrizi (Medicare) prior authorization request form - Prior Authorization Request","","Skyrizi (Medicare) prior authorization request form collects complete member, prescriber, and dispensing/pharmacy information to support a covered drug request. The form requires office notes, relevant labs, and medical testing demonstrating medical justification for the diagnosis, plus details on medication history, contraindications, and whether the request is new or a continuation. It also captures medication directions, dosing, and review turnaround time, and includes reauthorization and diagnosis selection questions.",{"@graph":14,"@context":72},[15,34,55],{"@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/skyrizi-medicare-prior-authorization-request-form-prior-authorization-request/288939/",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/skyrizi-medicare-prior-authorization-request-form-prior-authorization-request/288939.png","ImageObject",442,249,{"name":42,"@type":43},"Jordan Avery","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-10","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":26},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"How can the prior authorization request be submitted?","Question",{"text":62,"@type":63},"Use the Surescripts electronic prior authorization portal at providerportal.surescripts.net, or fax a completed prior authorization request form to 800-750-9692.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What information is required for the request to be reviewed?",{"text":67,"@type":63},"The form requires all requested data and includes required office notes, labs, and medical testing showing medical justification to support the diagnosis.",{"name":69,"@type":60,"acceptedAnswer":70},"Which clinical questions are included for Crohn's Disease, Ulcerative Colitis, and related diagnoses?",{"text":71,"@type":63},"The form includes questions on reauthorization response, applicable diagnosis selection, concomitant use with other biologics/targeted DMARDs, prescribing specialty, disease activity level, IV loading dose timing, and evidence of ulcers/strictures or perianal/penetrating disease on endoscopy.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288939,1791646648,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"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":81,"data":127},{"doc_id":78,"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":135,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"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":22},1099523882367,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Would you like to use electronic prior authoriztion? Consider using Surescripts, our electronic prior authorization portal at [providerportal.surescripts.net/ProviderPortal/login](providerportal.surescripts.net/ProviderPortal/login OR fax completed)[ OR fax completed](providerportal.surescripts.net/ProviderPortal/login OR fax completed) prior authorization request form to 800-750-9692.  \nAll requested data must be provided. Incomplete forms or forms without the chart notes will be returned  \n[Pharmacy Coverage Guidelines are available at ](Pharmacy Coverage Guidelines are available at sentarahealthplans.com/en/providers/authorizations/prescription-drugs)[sentarahealthplans.com/en/providers/authorizations/prescription-drugs](Pharmacy Coverage Guidelines are available at sentarahealthplans.com/en/providers/authorizations/prescription-drugs)  \nSkyrizi (Medicare)  \n\n| REQUIRED: Office notes, labs, and medical testing relevant to request showing medical justification to support diagnosis |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Member Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Member Name (first & last): |  |  |  |  |  |  | Date of Birth: |  |  |  |  |  |  | Gender: ☐Male ☐Female |  |  |  |  |  |  |  |  | Height: |  |\n| Member ID: |  |  |  |  | City: |  |  |  |  |  |  |  |  | State: |  |  |  |  |  |  |  |  | Weight: |  |\n| Prescribing Provider Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Requestor’s Name: |  |  |  |  |  |  |  | Requestor’s Phone Number: |  |  |  |  |  |  |  |  | Requestor’s Fax Number: |  |  |  |  |  |  |  |\n| Provider Name (first & last): |  |  | Specialty |  |  |  |  |  | NPI: |  |  |  |  |  |  |  |  |  | DEA: |  |  |  |  |  |\n| Office Address: |  |  |  |  |  | City: |  |  |  |  |  |  |  |  | State: |  |  |  |  | Zip Code: |  |  |  |  |\n| Office Contact: |  |  |  |  |  |  |  |  |  |  | Office Phone: |  |  |  |  |  |  | Office Fax: |  |  |  |  |  |  |\n| Dispensing Provider/Pharmacy Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Place of Administration: |  | ☐Self-Administered ☐Physician’s Office ☐Home ☐Home Infusion Center ☐Outpatient Infusion Center Name:   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Agency NPI: |  |  |  | Agency Name: |  |  |  |  |  |  |  |  | Agency Phone Number: |  |  |  |  |  |  |  |  |  |  |  |\n| Agency Address |  |  |  |  |  |  |  |  |  |  |  |  | Agency Fax Number: |  |  |  |  |  |  |  |  |  |  |  |\n| City: |  |  |  |  |  |  |  |  |  | State: |  |  |  |  |  |  | Zip: |  |  |  |  |  |  |  |\n| Dispensing Location: | ☐Retail Pharmacy ☐Mail Order ☐Physician’s Office ☐Specialty Pharmacy ☐Other |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Pharmacy Name: |  |  |  |  |  |  |  |  |  |  | Pharmacy Phone: |  |  |  |  |  |  |  |  |  | Pharmacy Fax: |  |  |  |\n| Pharmacy NPI: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Requested Medication Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication request is NOT for an FDA approved, or compendia-supported diagnosis (check one): ☐Yes ☐No |  |  |  |  |  |  |  |  |  |  |  | Diagnosis: |  |  |  |  |  |  |  |  |  | ICD-10 Code: |  |  |\n| Are there any contraindications to formulary medications?\u003Cbr>If yes, please specify: |  |  |  |  |  |  |  |  |  |  |  | Is this a New Request or Continuation of Therapy:☐New, start date:  / / \u003Cbr>☐Continuation, date of last treatment:  / /  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Directions for Use: |  |  |  |  |  |  |  |  |  |  |  | Strength: |  |  |  |  |  | Dosage Form |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  | Duration: |  |  |  | Quantity: |  |  |  |  |  |  |  | Days Sup","cbCaifk3lucdSa3F","https://ap.wps.com/l/cbCaifk3lucdSa3F","pdf",123465,8,"English","# Prior Authorization Setup\n## Electronic prior authorization and required submissions\n# Member Information\n## Required demographics\n# Prescribing Provider Information\n## Provider identifiers and contact details\n# Dispensing Provider/Pharmacy Information\n## Administration and pharmacy details\n# Requested Medication Information\n## Diagnosis, ICD-10, contraindications, and therapy type\n# Clinical Information Questions (Q1-Q8)\n## Reauthorization, diagnosis selection, and disease status","[{\"question\":\"How can the prior authorization request be submitted?\",\"answer\":\"Use the Surescripts electronic prior authorization portal at providerportal.surescripts.net, or fax a completed prior authorization request form to 800-750-9692.\"},{\"question\":\"What information is required for the request to be reviewed?\",\"answer\":\"The form requires all requested data and includes required office notes, labs, and medical testing showing medical justification to support the diagnosis.\"},{\"question\":\"Which clinical questions are included for Crohn's Disease, Ulcerative Colitis, and related diagnoses?\",\"answer\":\"The form includes questions on reauthorization response, applicable diagnosis selection, concomitant use with other biologics/targeted DMARDs, prescribing specialty, disease activity level, IV loading dose timing, and evidence of ulcers/strictures or perianal/penetrating disease on endoscopy.\"}]","Skyrizi (Medicare) prior authorization request form - Prior Authorization Request | PDF",1789634254]