Highmark Prior (Rx) Authorization Form

Updated June 02, 2022

A Highmark prior authorization form is a document used to determine whether a patient’s prescription cost will be covered by their Highmark health insurance plan. A physician must fill in the form with the patient’s member information as well as all medical details related to the requested prescription. Once the form is complete, send it by fax or mail to the appropriate addresses below.

  • Fax: 1 (866) 240-8123
  • Mail: Medical Management & Policy, 120 Fifth Avenue, MC P4207, Pittsburgh, PA 15222

How to Write

Step 1 – In “Patient Information”, supply the patient’s subscriber ID number, Highmark coverage group number, full name, phone number, date of birth, and full address.

Step 2 – In “Clinical / Medical Information”, specify the drug name, strength or dose, requested quantity per month, diagnosis, name of the carrier who paid for the most recent transplant, type of transplant, date of most recent transplant, and the most recent transplant payer.

Step 3 – In “Alternatives Tried / Used By Patient (if applicable)”, specify the following information regarding any alternative drugs tried by the patient: drug name, strength, and documentation of failure of therapy.

Step 4 – In “Medical Rationale / Reason for Drug Therapy / Treatment Plan”, provide any additional information to support the request.

Step 5 – In “Physician Information”, provide the physician’s name, NPI or Tax ID number, phone number, fax number, and full address. The physician will also need to provide their signature and the date.

Step 6 – Lastly, specify the medicare type, commercial type, and request type.