CurrentArizona Complete HealthPolicy N/A

Prior Authorization / Formulary Exception Request Fax Form

Customize your policy alerts

Sign up for all Arizona Complete Health policy alerts

Know when Arizona Complete Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This document describes Arizona Complete Health's faxable prior authorization and formulary exception request form and instructions for submitting requests (including use of CoverMyMeds) for providers and pharmacies serving AzCH members.

Policy Summary

PayerArizona Complete Health

PolicyPrior Authorization / Formulary Exception Request Fax Form

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization or formulary exception requests via CoverMyMeds (preferred) or fax the completed form to (833) 546-1508.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

(833) 546-1508Fax number for completed form submission

CoverMyMedsPreferred electronic submission service

(866) 399-0928Prior authorization status phone

(888) 788-4408Forms & guidelines phone

TucsonPharmacy Dept mailing city

Form Completion Criteria

Form completion criteria

Form completion and documentation requirements to process prior authorization or formulary exception requests:

Form must be fully completed to avoid a processing delay.

Include patient identifiers: Patient's Name, Date of Birth, Member ID, Patient's Phone, Patient's Address, and Gender.

Include provider information: Provider's Name, Provider Specialty, Contact Name, Provider's Address, NPI, Provider's Phone, and Provider's Fax.

Specify medication information: Medication Name and Strength, Quantity, Directions for Use and Duration, and whether this is a new start (Yes/No). If not a new start, provide Date of First Dose.

Provide diagnosis information: Diagnosis description and ICD-10 Code.

Provide medication history: Medications previously tried with dates of use (supporting documentation required).

Provide medical justification and supporting information: Chart notes required; labs required if applicable; include height and weight when relevant.

Indicate patient location for administration: Doctor's Office, Infusion Suite, Dialysis Center, Home, Outpatient Hospital, or Other (specify).

Identify who will supply the drug: Provider's Office (Buy/Bill), Dialysis Center, Specialty Pharmacy, Outpatient Hospital Pharmacy, Retail Pharmacy, or Other (specify). Include name of Provider/Facility/Pharmacy when applicable (no response needed for retail pharmacies).

For requests involving non-participating providers or outpatient pharmacies for inpatient administration, submit requests to AZCH_PharmacyProviderLiaison@azcompletehealth.com.

Diagnosis Coding

Diagnosis codingICD-10

ICD-10

Diagnosis code field required on form

Submission, Documentation, and Special Requests

Prior Authorization

Submit via CoverMyMeds or fax; check status by phone

Submit completed prior authorization or formulary exception requests via CoverMyMeds (preferred) or fax this completed form to (833) 546-1508. Form must be fully completed to avoid processing delays. For prior authorization status inquiries call (866) 399-0928.

Documentation Required

Required documentation to process request

Include complete patient identifiers, medication details, diagnosis and ICD-10 code, medication history, and medical justification with supporting chart notes/labs; provider signature is required. For injectable drugs also include servicing provider/NPI/TIN, procedure codes, total units/visits/days, and start and end dates.

Patient name, DOB, member ID, phone, address
Medication name and strength, quantity, directions/duration
Diagnosis and ICD-10 code
Medications previously tried with dates (supporting documentation required)
Medical justification and supporting information (chart notes; labs if applicable; height and weight)
Physician's signature and date

Note

Non-participating provider / inpatient administration submissions

Requests for medications to be covered when provided by a non-participating provider or an outpatient pharmacy for inpatient administration must be submitted to AZCH_PharmacyProviderLiaison@azcompletehealth.com.

Key Definitions and Details

Preferred electronic prior authorization submission service for AzCH — CoverMyMeds

Preferred electronic submission serviceCoverMyMeds (www.covermymeds.com/main/prior-authorization-forms/) — AzCH's preferred way to receive prior authorization requests

Alternative submission methodFax completed form to (833) 546-1508

Service descriptionFree electronic service to begin prior authorization submissions via CoverMyMeds

Additional required details for injectable drugs including NPI, TIN, procedure codes, units/visits/days, and dates — Servicing Provider information

Servicing provider identifiersServicing Provider name, Servicing NPI, Servicing TIN

Contact informationContact Name and Phone Number for the servicing provider/facility

Procedure and utilization detailsProcedure Codes and Total Units/Visits/Days

Treatment datesStart Date and End Date for the injectable administration

AttestationPhysician's Signature (required) and Date certifying information is correct

Policy Summary

PayerArizona Complete Health

PolicyPrior Authorization / Formulary Exception Request Fax Form

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization or formulary exception requests via CoverMyMeds (preferred) or fax the completed form to (833) 546-1508.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.