I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on …

This form is based on Express Scripts standard criteria and may not be applicable to all patients; certain plans and situations may require additional information beyond what is specifically requested.

PRIOR AUTHORIZATION REQUEST FORM Complete ENTIRE form and Fax to: 866-940-7328 ... Physician Signature: ___________________________________________ Date: …

NYS Medicaid Prior Authorization Request Form For Prescriptions Rationale for Exception Request or Prior Authorization – All information must be complete and legible

INDIANA MEDICAID Rx PRIOR AUTHORIZATION REQUEST FORM ... Prescriber Signature – Dispense as Written (DAW): Prescriber Signature – Substitution Permitted: …

I understand that Prior Authorizations will not exceed 6 months from date of fill for controlled medications and 1 year for non-controlled medications, except for Early Refill Requests, which are valid one time …

MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, …

Drug Prior Authorization Request Form Fax completed form to 217-524-7264, or call 1-800-252-8942 and provide all information requested below Typically, if a drug requires prior approval, alternatives …

Is the request for a patient with one or more chronic conditions (e.g., psychiatric condition, diabetes) who is stable on the current drug(s) and who might be at high risk for a significant adverse event with a …

MassHealth reviews requests for prior authorization on the basis of medical necessity only. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, …