Prior (Rx) Authorization Forms

Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions. A non-preferred drug is a drug that is not listed on the Preferred Drug List (PDL) of a given insurance provider or State. On the prior authorization form, the person making the request must provide a medical rationale as to why the chosen medication is necessary for the patient in question. If the patient has tried any preferred medications in treatment of the relevant diagnosis, the duration of therapy and reason for failure will be described in the form as supporting justification for making this request. Any relevant clinical data and medical documents should also be attached with this form when it is submitted to the insurance provider. Once completed, this form should be faxed or mailed to the correct directory for processing

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How to Write

Step 1 – At the top of the Global Prescription Drug Prior Authorization Request Form, you will need to provide the name, phone number, and fax number for the “Plan/Medical Group Name.”

Step 2 – In the “Patient Information” section, you are asked to supply the patient’s full name, phone number, complete address, date of birth, gender, height, weight, allergies (if applicable), and authorized representative information (if known).

Step 3 – Next, in the “Insurance Information” section, you must provide the name and ID number of the patient’s primary and, if applicable, secondary insurance providers.

Step 4 – In “Prescriber Information,” you will have to enter the prescriber’s full name, specialty, and complete address; the requestor’s name (if different from the prescriber), and the prescriber’s office contact person, NPI number, phone number, DEA number, fax number, and email address.

Step 5 – Beneath “Medication/Medical and Dispensing Information,” enter the name of the medication where indicated and indicate whether this is a new therapy or a renewal. If it is a renewal, you will need to provide the date therapy was initiated, the duration, and how the patient received this medication. Next, supply the dose/strength, frequency, length of therapy/number of refills, quantity, method of administration, and the location of the prescriber’s administration.

Step 6 – Enter the patient’s name and ID number into the indicated fields at the top of page 2.

Step 7 – Next, indicate whether the patient has tried other medications to treat this diagnosis and list the name, duration of therapy, and reason for failure for each applicable prescription.

Step 8 – Beneath “List Diagnoses,” write the diagnoses relevant to this request and their associated ICD-9/ICD-10 codes.

Step 9 – In the “Required Clinical Information” section, write your clinical justifications for making this request in the blank field and, if you are attaching supporting medical documentation, check the checkbox marked “Attachments.”

Step 10 – When you have finished filling out the document, you will need to provide the prescriber’s signature and the date.