[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-detail-287223-en":53,"doc-seo-287223-105":73},{"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":5,"data":54},{"doc_id":55,"user_id":56,"nickname":57,"user_avatar":58,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":60,"doc_content":61,"file_id":62,"file_url":63,"file_type":64,"file_size":65,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":66,"language_code":67,"site_id":68,"html_lang":67,"table_of_contents":69,"faqs":70,"seo_title":71,"seo_description":60,"update_tm":72,"read_time":4},287223,1099514067438,"River Wang","https://ap-avatar.wpscdn.com/avatar/100002539ee87300030?x-image-process=image/resize,m_fixed,w_180,h_180&k=1780474512215547542","UniversalPriorAuth_Medications_FORM - Prior Authorization Request Form - Medications","Medications prior authorization request form for collecting provider, member, and drug details required to support coverage decisions. Includes sections for prescriber and pharmacy information, member identifiers and plan selection, and one-drug-per-request medication data such as strength, dosage form, interval, quantity, diagnosis and ICD-9 code, expected therapy duration, and refills. Captures drug history for the diagnosis, questions on office vs home administration and prior approvals, and documentation of previous therapies. Requires a medical-necessity rationale, additional clinical information attachment, and prescriber signature and date, plus plan fax submission numbers.","I. Provider Information  \nPrior Authorization Request Form: Medications  \nPlease type or print neatly. Incomplete and illegible forms will delay processing.  \nII. Member 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\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>Use the drop down to select the appropriate health plan. |  |\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  \nRev. 04192013  \nAbsolute Total Care . . . ... . . .. . . . . 1.866.399.0929 Advicare... . . . ... . .. .. . .. .. . . 1.866.255.7569 BlueChoice HealthPlan Medicaid . . . 1.866.807.6241 FFS Medicaid.. . . .. . .. .. . .. .. . . . . 1.888.603.7696  \nFirst Choice by Select Health. . . . . ... . 1.866.610.2775 Molina Healthcare of SC. . . . . . . ... . 1.855.571.3011 Wellness of SC. ... . .. .. . .. .. . .... . 1.866.354.8709","cbCaiqgAQvNMKiMY","https://ap.wps.com/l/cbCaiqgAQvNMKiMY","pdf",565845,"English","en",105,"# Provider Information\n# Member Information\n# Drug Information\n# Drug History for this Diagnosis\n# Rationale for Request and Pertinent Clinical Information\n# Plan Fax Numbers","[{\"question\":\"What information is required in the Provider Information section?\",\"answer\":\"Enter prescriber details such as name, NPI number, specialty, phone and address, office contact name, and pharmacy name and phone for submission.\"},{\"question\":\"How should the medication details be completed?\",\"answer\":\"Submit one drug per request form, including drug name, strength, dosage form, dosage interval, quantity per day, diagnosis and ICD-9 code, expected therapy length, and number of refills.\"},{\"question\":\"What does the drug history section ask for?\",\"answer\":\"It asks whether the prescription is for office administration or home use, whether the member is currently on the drug, whether this is a continuation of a previous approval, whether strength/dosage/quantity changed, and to list previous treatments with outcomes.\"}]","UniversalPriorAuth_Medications_FORM - Prior Authorization Request Form - Medications | PDF",1789632038,{"code":4,"msg":74,"data":75},"ok",{"site_id":68,"language":67,"slug":76,"title":59,"keywords":77,"description":60,"schema_data":78,"social_meta":134,"head_meta":136,"extra_data":138,"updated_unix":139},"universalpriorauth_medications_form-prior-authorization-request-form-medications","",{"@graph":79,"@context":133},[80,96,116],{"@type":81,"itemListElement":82},"BreadcrumbList",[83,87,90,93],{"item":84,"name":85,"@type":86,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":88,"name":10,"@type":86,"position":89},"https://docshare.wps.com/template/",2,{"item":91,"name":36,"@type":86,"position":92},"https://docshare.wps.com/template/forms/",3,{"item":94,"name":59,"@type":86,"position":95},"https://docshare.wps.com/template/universalpriorauth_medications_form-prior-authorization-request-form-medications/287223/",4,{"url":94,"name":59,"@type":97,"image":98,"author":103,"headline":59,"publisher":105,"fileFormat":108,"inLanguage":67,"description":60,"dateModified":109,"datePublished":110,"encodingFormat":108,"isAccessibleForFree":111,"interactionStatistic":112},"DigitalDocument",{"url":99,"@type":100,"width":101,"height":102},"https://docshare.wps.com/thumbnails/universalpriorauth_medications_form-prior-authorization-request-form-medications/287223.png","ImageObject",442,249,{"name":57,"@type":104},"Person",{"url":84,"name":106,"@type":107},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":113,"interactionType":114,"userInteractionCount":47},"InteractionCounter",{"@type":115},"ViewAction",{"@type":117,"mainEntity":118},"FAQPage",[119,125,129],{"name":120,"@type":121,"acceptedAnswer":122},"What information is required in the Provider Information section?","Question",{"text":123,"@type":124},"Enter prescriber details such as name, NPI number, specialty, phone and address, office contact name, and pharmacy name and phone for submission.","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"How should the medication details be completed?",{"text":128,"@type":124},"Submit one drug per request form, including drug name, strength, dosage form, dosage interval, quantity per day, diagnosis and ICD-9 code, expected therapy length, and number of refills.",{"name":130,"@type":121,"acceptedAnswer":131},"What does the drug history section ask for?",{"text":132,"@type":124},"It asks whether the prescription is for office administration or home use, whether the member is currently on the drug, whether this is a continuation of a previous approval, whether strength/dosage/quantity changed, and to list previous treatments with outcomes.","https://schema.org",{"og:url":94,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":94},"index,follow",{"doc_id":55,"site_id":68},1790202013]