CurrentAmeriHealthPolicy N/A

Dispense As Written (DAW) Override Prior Authorization Request Form

Form and instructions for providers requesting a DAW override prior authorization from AmeriHealth; collects provider, medication, clinical, and medication-history information to support coverage of brand product when substitution is possible.

Policy Summary

PayerAmeriHealth

PolicyDispense As Written (DAW) Override Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed DAW Override Prior Authorization Request Form with diagnosis (ICD-10), complete medication history of generics tried/failed, and any allergy/intolerance details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4required form sections

ICD-10diagnosis coding requested

DAWoverride type

Coverage Criteria

Initial DAW Override Criteria

Coverage for a DAW override is supported when ALL of the following are provided:

Complete form and clinical justification: Completed provider and member information, and complete medication information including medication name, strength, dosage form, directions for use, and indication whether generic substitution is acceptable.

Supported by form fields requesting provider/member and medication information (chunks 2 and 4).

Diagnosis coding: The patient’s diagnosis for the requested medication and the corresponding ICD-10 code(s).

Clinical Information section requests diagnosis and ICD-10 code(s).

Medication history of generics tried: A complete list of ALL generic equivalents of the requested drug that the patient has tried and failed, and specification of the number of generic equivalents from different manufacturers tried.

Policy Summary

PayerAmeriHealth

PolicyDispense As Written (DAW) Override Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed DAW Override Prior Authorization Request Form with diagnosis (ICD-10), complete medication history of generics tried/failed, and any allergy/intolerance details.

SourceLink

On This Page

Provider Actions & Requirements

Prior Authorization

DAW Override Prior Authorization Requirement

Submission of a completed DAW Override Prior Authorization Request Form is required for any Dispense As Written (DAW) override request. Do not submit partial forms; use the current form version available from AmeriHealth.

Completed DAW Override Prior Authorization Request Form must be submitted
Use latest AmeriHealth form version

Documentation Required

Prior trial documentation

The request must include documentation of prior trials: list every generic equivalent of the requested drug that the member has tried and failed, and specify the number of different manufacturer generics tried.

List ALL generic equivalents tried and failed
Specify number of generics from different manufacturers tried

Documentation Required

Required documentation on form

Providers must complete all required fields on the form to support clinical review. Required documentation includes member and provider identifiers, medication details, and clinical justification fields.

Member identifiers: Member name, Insurance ID#, Date of birth, Zip
Provider identifiers: Provider name, NPI#, Specialty, Office phone, Office fax, Street address, City, State
Medication details: Medication name, Strength, Dosage form, Directions for use, Indicate if generic substitution is acceptable, Indicate if request is for continuation of therapy
Clinical justification: Diagnosis and ICD-10 code(s), Clinical explanation for DAW override, Any allergic reactions or intolerance to inactive ingredients, Documentation of inadequate response to generic equivalents, Additional relevant clinical comments

Denial Risk

Incomplete submission risk

Requests may be denied if required information is missing. Incomplete submissions risk denial unless all required information is received.

Incomplete or missing fields may result in denial
Provide full medication history and clinical justification to avoid delays

Background

This DAW Override Prior Authorization Request Form is designed to capture the clinical justification a prescriber must provide when requesting that a pharmacy dispense a brand product "as written" instead of a generic. The medication-history section requires a complete listing of all generic equivalents tried and failed, the number of generics from different manufacturers tried, and whether the patient has had an allergic reaction or intolerance to an inactive ingredient or an inadequate response to the generic equivalent. The form also provides space for any additional comments, diagnoses, symptoms, or medications tried/failed to support the clinical rationale.

Definitions

DAW override — Dispense As Written (DAW) Override definition

TermDispense As Written (DAW) Override

DefinitionA prior authorization request to have a pharmacy dispense the brand product 'as written' instead of an available generic substitution.

Form usedDAW Override Prior Authorization Request Form

PurposeCapture clinical justification, diagnosis (ICD-10), and complete medication history to support a brand DAW override.

Required supporting detailsProvider and member identifiers, medication details, diagnosis with ICD-10 code(s), and history of generic equivalents tried and failed.

Continuation Criteria

Continuation

Continuation requests

Continuation of therapy indicator: Request must indicate that it is for continuation of therapy (form includes a checkbox to indicate continuation) and include any prior authorization or prior coverage details as applicable.

Medication information includes a checkbox for continuation of therapy (chunk 2); medication history and notes remain required (chunk 4).

Step Therapy / Trial History

Generic equivalent tried (name)	Manufacturer (if known)	Outcome (tried/failed)	Allergic reaction/intolerance to inactive ingredient	Inadequate response to generic equivalent
Please list ALL generic equivalents of the requested drug that the patient has tried and failed:
Please specify the number of generic equivalents from different manufacturers the patient has tried:
Has the patient had an allergic reaction or intolerance to an inactive ingredient? (Yes/No)
Has the patient experienced an inadequate response to the generic equivalent? (Yes/No)
Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review?

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