Dispense As Written (DAW) Override Prior Authorization Request Form
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Form and instructions for providers to request a prior authorization to override generic substitution (Dispense As Written) for a medication; applies to AmeriHealth members and their prescribing providers submitting DAW override requests to the pharmacy benefit manager.
No material clinical or coverage changes in this revision.
Coverage Criteria
Submission completeness criteria
Coverage decision is based on submission of required information and clinical rationale.
Incomplete submissions may be denied.
No explicit exclusion conditions are listed on the DAW Override Prior Authorization Request Form. The form focuses on documenting the clinical rationale and prior medication history needed to consider a Dispense As Written (DAW) override rather than listing situations that would automatically exclude a request.
The form states clearly that this request may be denied unless all required information is received. Missing required fields—such as medication history, number of manufacturers tried, documentation of allergic intolerance to inactive ingredients, or clinical justification—can result in the request being denied as incomplete.
Diagnosis / Coding
| ICD-10 Code(s) | Field for the applicable diagnosis code(s) |
Provider Actions & Requirements
DAW Override prior authorization required
Prior authorization to override generic substitution must be requested using the DAW Override Prior Authorization Request Form; complete the form with member, provider, medication, clinical diagnosis/ICD-10, medication history of generics tried, and supporting clinical rationale to request the DAW override.
Indicate continuation of therapy on form
The form includes a checkbox to indicate if the request is for continuation of therapy; providers must mark this box when applicable, though no additional step-therapy failure sequence is specified on the form beyond listing prior generic trials.
Complete all required form fields
Providers must complete all required form fields: member information, provider information (including NPI), medication details (name, strength, dosage form, directions), clinical diagnosis and ICD-10 code(s), and a medication history documenting all generic equivalents tried and failed, number of manufacturers tried, and any allergic reaction/intolerance or inadequate response.
- Member and insurance identifiers (Member Name, Insurance ID#, DOB)
- Provider information including Provider Name and NPI#
- Medication name, strength, dosage form, and directions
- Checkboxes: generic substitution acceptable; continuation of therapy
- Clinical diagnosis and ICD-10 Code(s)
- Medication history: all generic equivalents tried, number of manufacturers tried, allergic intolerance and inadequate response fields
Risk of denial for incomplete submission
This request may be denied if all required information is not provided; ensure every required field and the medication history are completed to avoid denial for incomplete submission.
- Incomplete submissions may be denied as noted on the form: "This request may be denied unless all required information is received."
Background
This DAW Override form is intended to support the clinical justification for dispensing a prescribed brand or specific formulation instead of an interchangeable generic equivalent. Providers must document the diagnosis and the patient’s prior therapeutic experience with generic equivalents, including which generics were tried and failed, the number of different manufacturers attempted, and whether there were allergic reactions or intolerances to inactive ingredients, so that the pharmacy benefit manager can evaluate the request.
Definitions
Continuation of Therapy Criteria
Continuation of therapy
Continuation requests
No additional continuation-specific criteria or required duration provided on the form; include medication history and clinical rationale as part of the submission.
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