Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may use the attached …

Does the patient require a specific dosage form (e.g., suspension, solution, injection)? If so, please provide dosage form: Are additional risk factors (e.g., GI risk, cardiovascular risk, age) …

Starting June 1, 2023, all prior authorization requests need to be submitted electronically. It’s easy to work with us on Availity . It will help you stay compliant and you can take advantage of …

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on …

please fax completed form to 1-888-836-0730. I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, …

· Prior Authorization (PA): Some drugs require you or your prescriber to get prior authorization. You must get an approval from us before you can get your prescription

Use this form to request coverage of a drug that is not on the formulary. To process this request, documentation that all formulary alternatives would not be as effective or would have adverse …

Required clinical information - Please provide all relevant clinical information to support a prior authorization or step therapy exception request review. Please provide symptoms, lab results …

If a form for the specific medication cannot be found, please use the Global Prior Authorization Form. California members please use the California Global PA Form . To access other state …

Prior Authorization/Precertification* Request for Prescription Medications Fax this form to: 1-877-269-9916 OR Submit your request online at: https://www.availity.com Visit …