CurrentDenver-Health-Medical-PlanPolicy N/A

UNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

A standardized form and instructions for submitting pharmacy prior authorization (PA) requests to Denver Health Medical Plan's Pharmacy Department, including patient, prescriber, drug, clinical justification, and delivery information. Contains guidance on opioid-dependence medications and statutory PA exceptions effective Jan 1, 2020.

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyUNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionComplete the form in its entirety and mail or fax to the Denver Health Medical Plan Pharmacy Department at the address or fax provided; include patient, prescriber, drug details, clinical criteria, prior medications tried, and dispensing pharmacy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — standardized PA form and statutory exceptions remain informational.

1Statutory change referenced (Jan 1, 2020)

303-602-2081Fax for PA submissions

Policy overview

Scope/Title: Uniform Pharmacy Prior Authorization Request Form — a standardized form and instructions for submitting pharmacy prior authorization (PA) requests to Denver Health Medical Plan's Pharmacy Department. Status: CURRENT.

This form collects required fields including patient and prescriber information, patient diagnosis (ICD-10), drug details (including J-code if applicable), clinical rationale and prior medications tried, and delivery/location details and dispensing pharmacy. Complete and mail or fax the form to the Pharmacy Department at the address or fax provided.

Statutory limitation: As of January 1, 2020, no prior authorization requirements may be imposed by a carrier for any FDA‑approved prescription medication on its formulary which is approved to treat substance use disorders. For opioid‑dependence medications, if the request is a first request within 12 months a 5‑day supply of any FDA‑approved drug for treatment of opioid dependence does not require PA and the form need not be completed; if not a first request, PA is not required for on‑formulary medications as of Jan 1, 2020 and the form need not be completed.

Key Metadata

PayerDenver-Health-Medical-Plan

PolicyUNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

Policy NumberN/A

Effective Date

StatusCURRENT

Scope summaryA standardized form and instructions for submitting pharmacy prior authorization (PA) requests to Denver Health Medical Plan's Pharmacy Department, including patient, prescriber, drug, clinical justification, and delivery information. Contains guidance on opioid-dependence medications and statutory PA exceptions effective Jan 1, 2020.

Fax303-602-2081

Statutory change referenced (Jan 1, 2020)yes

Opioid-dependence prior authorization exceptions

Opioid Dependence Prior Authorization Exception

Statutory exceptions regarding prior authorization for FDA-approved medications for opioid dependence as of January 1, 2020:

ALL of the following

If the requested drug is intended to treat opioid dependence AND this is a first request within a 12-month period for PA for this drug, then prior authorization is not required for a 5-day supply of any FDA-approved drug for treatment of opioid dependence.
Do not complete this form for a first request for a 5-day supply.
If the requested drug is intended to treat opioid dependence AND this is not a first request within a 12-month period, then as of Jan 1, 2020, prior authorization is not required for prescription medications on the carrier's formulary.
Do not complete this form if the drug is on-formulary; form not required per statute.

Operational impact: Do not complete or submit this PA form when the requested drug is intended to treat opioid dependence and either (1) it is a first request within a 12‑month period for which a 5‑day supply is requested, or (2) the medication is an FDA‑approved prescription on the carrier's formulary — in both cases effective January 1, 2020 no PA is required.

What providers must do

Documentation Required

Complete and submit PA form

Complete the form in its entirety and mail or fax to the Denver Health Medical Plan Pharmacy Department at the address or fax provided. The form must include patient, prescriber, drug details, clinical criteria, prior medications tried, and dispensing pharmacy.

Required form elements: patient information; prescriber information; drug name (with J‑code if applicable), strength/route/frequency; clinical criteria and other medications tried (names, duration, response); dispensing pharmacy name and phone number.
Submission methods: Mail to 777 Bannock St., MC 6000, Denver, CO 80204 or fax to 303-602-2081 (Attn: Pharmacy Department).

Prior Authorization

Urgent vs Non-Urgent designation

Mark the request as Urgent or Non-Urgent on the form. Urgent requests must meet the statutory criteria for time-sensitive review (i.e., situations that could seriously jeopardize life or health, the ability to regain maximum function, or cause severe unmanaged pain).

See definition of 'Urgent' (request that if determined in the time allowed for non-urgent requests could seriously jeopardize life or health, ability to regain maximum function, or cause severe unmanaged pain).

Documentation Required

Opioid‑dependence PA handling

Do not submit this form for a first request within a 12-month period for a 5-day supply of FDA-approved medications intended to treat opioid dependence. Do not submit the form for on‑formulary opioid‑dependence prescription medications on or after January 1, 2020, as prior authorization is not required.

Statutory exception: PA not required for a first 5-day supply within 12 months, and PA not required for on-formulary opioid‑dependence medications effective Jan 1, 2020.

Documentation Required

Denial notification requirements

When a request is denied, the response must provide the reason for denial and, if applicable, include other potential alternative medications that are found on the carrier's formulary.

Submission contacts and referenced billing fields

Contact / Submissionmixed

Fax	303-602-2081 for Pharmacy Department submissions
Address	777 Bannock St., MC 6000, Denver, CO 80204

Request fields referencing billing codesmixed

J-Code	Field for J-code if applicable for drugs administered under medical benefit
ICD-10	Field for patient diagnosis and ICD diagnostic code(s)

Billing codes on the form: Use the J‑Code field for drugs administered under the medical benefit (enter J‑code if applicable) and use the ICD‑10 field to record the patient diagnosis and diagnostic code(s).

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyUNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

UNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

Policy overview

Opioid-dependence prior authorization exceptions

What providers must do

Submission contacts and referenced billing fields

Definitions

Document changes