Member plan ID # Date of birth
Plan name and fax for form submission
Universal Medication Prior Authorization Form
Please type or print neatly. Incomplete and illegible forms will delay processing.
Prescriber name NPI #
Pharmacy name Pharmacy phone
Drug name Drug strength Dosage form Dosage interval Quantity per day
Diagnosis relevant to this request
Expected length of therapy Number of refills
Drug History for
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.
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
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
Molina Healthcare of SC
WellCare of SC ..... . ..
Use the drop down to select the appropriate health plan.