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Peia prior authorization form 2025

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The document is a Prior Authorization Form for Buprenorphine and Buprenorphine/Naloxone, intended for use by prescribers in West Virginia. It includes sections for patient and prescriber information, medication details, diagnosis codes, and attestation of medical necessity. The form emphasizes confidentiality and legal protections regarding health information, as well as the requirement to review the patient's medication history. It also contains important notes about specific medications and warnings related to their use.

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Click ‘Get Form’ to open the PEIA Prior Authorization Form in our platform's editor.
Begin by entering the patient's name in the designated fields, ensuring you include their last name first.
Next, fill in the prescriber's information, including their name, address, and 10-digit NPI number. This is crucial for proper identification.
Input the patient's date of birth and contact details. Make sure to format the phone numbers correctly.
If applicable, provide pharmacy details including name and address. This helps streamline communication regarding medication.
Complete the diagnosis section by entering the ICD Diagnosis Code and any other pertinent information required for medical necessity.
Review all sections carefully before signing electronically or manually at the end of the form to certify that all information is accurate.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is UMR and PEIA the same?

7:00 a.m. - 7:00 p.m. UMR is PEIAs third-party administrator that handles medical claim processing, case management, utilization management, precertification, prior approval and customer service for the PEIA PPB Plans. Contact UMR for answers to questions about eligibility, benefits and networks.

What are prior authorization forms?

A prior authorization form will include information about you, your medical conditions, and your health care needs. Its important to fill out the form completely and accurately. Incomplete or incorrect information could delay your request or result in a denial.

What is the difference between Plan A and Plan B insurance?

Part A provides hospital coverage, while Part B covers doctors visits and other aspects of outpatient medical care. These plans arent competitors but complement each other, providing both outpatient and inpatient health coverage.

What is PPB insurance?

What does Personal portfolio bond (PPB) mean? Broadly, a life assurance policy, contract for a life annuity or capital redemption policy where the policyholder has the power to select the underlying investments.

How much is the PEIA spousal surcharge?

Starting July 1, 2025, the Spousal Surcharge will be increasing to $350* per month.

rational drug therapy prior auth form

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What does PEIA stand for?

Public Employees Insurance Agency 601 57th St., SE, Suite 2. Charleston, WV 25304-2345.

What is the difference between PEIA plan A and B?

PEIA PPB Plans The medical coverage is identical in PPB Plans A and B. The differences are in the annual deductible, out-of-pocket maximums and drug co-payments. PEIA PPB Plan C is an IRS-qualified High Deductible Health Plan which can be paired with a Health Savings Account (HSA).