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The document is a Pharmacy Prior Authorization Request Form for USFHP, designed to assess the medical necessity of non-formulary medications. It allows providers to request that a non-formulary medication be covered at a lower formulary cost if deemed necessary. The form requires patient and provider information, details about the medication and diagnosis, previous treatment trials, and supporting documentation. It also includes attestations for accuracy and completeness.

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Click ‘Get Form’ to open the Pharmacy Prior Authorization Request Form in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's name, address, sponsor ID number, date of birth, and phone number.
Next, complete the 'Provider Information' section with the provider's name, address, and secure fax number.
In the 'Medication Information' section, specify the medication name, strength, dosage form, directions for use, and provide the patient's diagnosis along with ICD-10 codes.
Detail why formulary medications are not suitable for this patient. List all medications tried along with any intolerances or contraindications.
Document previous formulary trials by entering drug names, strengths/dosages, trial dates and durations, and treatment outcomes.
Ensure that you attach supporting progress notes as required. Check off the attestations confirming that clinical documentation is attached and that information is accurate.
Finally, have the provider sign and date the form before submitting it via fax to ensure timely processing.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (77 Votes)

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Sixth form is part of (or attached to) a school whereas college is an independent entity.

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Form students 2026

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