Medication prior authorization request form 2026

1. Click ‘Get Form’ to open the medication prior authorization request form in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Ensure all required fields, such as member ID and date of birth, are completed accurately.
3. Next, move to the PRESCRIBER INFORMATION section. Fill in the prescriber’s name, NPI or DEA number, and contact details. This information is crucial for processing your request.
4. In the Drug Information section, specify the drug name, dosage form, strength, and directions for use. Make sure to include therapy start and end dates.
5. Complete the DIAGNOSIS section by providing the ICD10 code and diagnosis date. Include any relevant clinical information that supports your request.
6. Fill out the MEDICATION HISTORY section carefully. Indicate if the member is currently on this medication and provide details about previous treatments.
7. Finally, sign where indicated in the RATIONALE FOR REQUEST section. Ensure all required fields are filled before submitting your form.

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