Ambetter - Prior Authorization Form Prior Authorization Request Form for Prescription Drugs 2025

1. Click ‘Get Form’ to open the Ambetter - Prior Authorization Form in the editor.
2. Begin by filling out the Provider Information section. Enter the prescriber name, office contact name, and relevant contact details including fax and phone numbers.
3. Next, complete the Member Information section. Input the member's name, identification number, date of birth, and any medication allergies.
4. In the Drug Information section, specify the drug name and strength, dosage form, diagnosis related to this request, dosage interval, ICD-10 code, and expected length of therapy.
5. Indicate whether you are requesting a formulary or step-therapy exception by checking 'Yes' or 'No'.
6. Provide medication history for this diagnosis. Answer if the member is currently treated on this medication and fill in additional details as required.
7. In Section IV, provide a rationale for your request along with any pertinent clinical information that supports medical necessity.
8. Finally, ensure you sign and date the form before submitting it via fax or mail as indicated.

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