Member plan ID # Date of birth
Plan name and fax for form submission
I.
Provider
Inf
orma
tion
Universal Medication Prior Authorization Form
Please type or print neatly. Incomplete and illegible forms will delay processing.
II. Member
Inf
orma
tion
Prescriber name NPI #
Prescriber address
Pharmacy name Pharmacy phone
III.
Drug Information
(one
drug
per request
f
orm)
Drug name Drug strength Dosage form Dosage interval Quantity per day
Diagnosis relevant to this request
ICD code
Expected length of therapy Number of refills
IV.
Drug History for
this
Dia
gno
sis
A. Is the prescription for a drug to be administered in the office or for the member to take at home? office home
B. Is the member currently treated on this drug? Yes: how long? [go to item C] No [skip items C and D; go to item E]
C. Is this request for continuation of a previous approval? Yes [go to item D] No [skip item D; go to item E]
D. Has strength, dosage or quantity required per day increased or decreased?
Yes [go to item E] No [skip item E; indicate rationale in Section V and submit form]
E. Please indicate previous treatments and outcomes with other medications below.
Drug
name S
trength
Dire
c
tions
Dates of
the
r
apy
Reason
for failure
or
dis
c
ontinu
a
tion
V.
Rationale for
Request and
Pertinent Clinical Information (attach additional
sheets if more space is needed)
Appropriate clinical information to support the request on the basis of medical necessity must be submitted.
Prescriber/Authorized Representative signature Date
Plan Fax
Number
s
Rev. 06/25/2019
Absolute Total Care . . ..... .... ...1.877.386.4695 Healthy Blue by Blue Choice of SC. . 1.844.512.9005
FFS Medicaid. ...................1.888.603.7696
First Choice by Select H
ealth. ......1.866.610.2775
Molina Healthcare of SC
...........1.855.571.3011
WellCare of SC ..... . ..
...........1.866.354.8709
Use the drop down to select the appropriate health plan.
