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Highmark wholecare prior authorization form pdf

Gateway prior auth form 2025

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The document is a Non-Formulary Drug Exception Form used to request prior authorization for specific medications not included in the formulary. It requires member and pharmacy information, clinical details about the requested drug, documentation of previous formulary alternatives tried, and prescriber information. The form must be faxed to a designated number, and if denied, prescribers can either switch to a formulary alternative or appeal the decision.

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Click ‘Get Form’ to open the gateway prior auth form in the editor.
Begin with SECTION A - MEMBER INFORMATION. Fill in the last name, first name, date of birth, member ID, and any known allergies along with the type of reaction(s).
Proceed to SECTION B - PHARMACY INFORMATION. Enter the pharmacy name and phone number where the prescription will be filled.
In SECTION C - CLINICAL INFORMATION, provide details such as dosage and frequency, quantity, drug name requested, and diagnosis for which the drug is being requested. Document any formulary alternatives that have been used by listing drug names, dates tried, and reasons for therapy failure.
Indicate if the member is currently or recently hospitalized by checking 'Yes' or 'No', and provide the date of discharge along with the reason for hospitalization if applicable.
Add any additional clinical or supporting information in the designated area.
Complete SECTION D - PRESCRIBER INFORMATION by entering prescriber name (printed), specialty, NPI number, office phone, office fax, and obtaining a signature along with the date.

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Versions	Form popularity	Fillable & printable
2011	4 Satisfied (32 Votes)

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