[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283853-105":53,"doc-detail-283853-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","youthcare-pharmacy-prior-authorization-request-form-updated-24220","YouthCare Pharmacy Prior Authorization Request Form - Updated 2.4.220","","Prescription Drugs Prior Authorization Request Form for YouthCare, collecting provider and member details, including prescriber name/NPI, office contact, fax/phone, member identification number, group information, and date of birth. Includes drug information for a single medication request with diagnosis, dosage, dosage interval (SIG), quantity per day, medication allergies, and expected length of therapy. Requires therapy history and rationale/pertinent clinical information for medical necessity, plus provider signature and submission guidance via CoverMyMeds, fax, phone, or mail.",{"@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/youthcare-pharmacy-prior-authorization-request-form-updated-24220/283853/",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/youthcare-pharmacy-prior-authorization-request-form-updated-24220/283853.png","ImageObject",442,249,{"name":88,"@type":89},"Mali","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-01","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should prior authorization requests be submitted for this form?","Question",{"text":108,"@type":109},"Use CoverMyMeds as the preferred method, or call the provided phone number, fax the completed form, or mail requests to the Pharmacy Services PA department address listed on the form.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required in the provider and member sections?",{"text":113,"@type":109},"The provider section requires prescriber name and NPI plus office contact details; the member section requires member name, identification number, group number/name, date of birth, and medication allergies.",{"name":115,"@type":106,"acceptedAnswer":116},"What must be included to support the prior authorization request?",{"text":117,"@type":109},"Complete the drug information for one drug, provide medication history for the diagnosis (including whether it is current treatment or a continuation), and include the required rationale/pertinent clinical information demonstrating medical necessity.","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},283853,1790020330,{"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":20,"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},2336475104362,"https://ap-avatar.wpscdn.com/avatar/22000c4c46a41b752dd?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786595829695023868","Prescription Drugs Prior Authorization Request Form  \nCoverMyMeds is the preferred way to receive prior authorization requests. Visit account.covermymeds.com to begin using this free service.  \nOR Call 1.833.491.0418 OR FAX this completed form to 1.844.205.3384  \nOR Mail requests to: Pharmacy Services 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| Prescriber NPI: |  |  | Identification number: |  |  |  |\n| Office contact name: |  |  | Group number: |  |  |  |\n| Group name: |  |  | Date of Birth: |  |  |  |\n| Fax: |  |  | Medication allergies: |  |  |  |\n| Phone: |  |  |  |  |  |  |\n| III. DRUG INFORMATION (One drug request perform) |  |  |  |  |  |  |\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 YouthCare HealthChoice Illinois Formulary is available on the YouthCare website at [www.ilyouthcare.com/providers/pharmacy.html](www.ilyouthcare.com/providers/pharmacy.html under the Preferred Drug List)[ under the Preferred Drug List](www.ilyouthcare.com/providers/pharmacy.html under the Preferred Drug List) (PDL) link. |  |  |  |  |  |  |\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\nPharmacy Services will respond via fax or phone within 24 hours of receipt.  \nRequests for prior authorization (PA) must include member name and 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.)  \nFor additional questions, call the Pharmacy Help Desk: 1.833.491.0418  \nRev.1221","cbCaiiAztoRfaX7e","https://ap.wps.com/l/cbCaiiAztoRfaX7e","pdf",174743,"English","# Provider information\n# Member information\n# Drug information\n## Medication history\n# Rationale for request / pertinent clinical information","[{\"question\":\"How should prior authorization requests be submitted for this form?\",\"answer\":\"Use CoverMyMeds as the preferred method, or call the provided phone number, fax the completed form, or mail requests to the Pharmacy Services PA department address listed on the form.\"},{\"question\":\"What information is required in the provider and member sections?\",\"answer\":\"The provider section requires prescriber name and NPI plus office contact details; the member section requires member name, identification number, group number/name, date of birth, and medication allergies.\"},{\"question\":\"What must be included to support the prior authorization request?\",\"answer\":\"Complete the drug information for one drug, provide medication history for the diagnosis (including whether it is current treatment or a continuation), and include the required rationale/pertinent clinical information demonstrating medical necessity.\"}]","YouthCare Pharmacy Prior Authorization Request Form - Updated 2.4.220 | PDF",1789620901]