Uc davis prior auth for pharmacy 2026

1. Click ‘Get Form’ to open the UC Davis Prior Authorization for Pharmacy in the editor.
2. Begin by filling out the Member Information section. Enter the member's last name, first name, middle initial, and Amerigroup ID number. Specify their place of residence and date of birth.
3. In the Medication Information section, provide the drug name and strength requested. Include dosage instructions (SIG) and indicate if the member has tried other medications for this condition.
4. Complete the Diagnosis and/or indication field along with any required ICD/Diagnosis codes. If applicable, describe any adverse reactions or inadequate responses experienced by the member.
5. Fill in the Prescriber Information with your details including NPI number and contact information. Ensure all fields are completed accurately to avoid processing delays.
6. Finally, review all entered information for accuracy before signing at the bottom of the form. Click ‘Submit’ to send your completed form directly through our platform.

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