Medication Prior Authorization Form - Coverage Criteria
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Form and instructions to request prior authorization for prescription medications for Highmark members; used by prescribing providers to submit clinical and administrative information required for authorization decisions.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization criteria
Coverage is considered when required documentation and criteria are provided.
Submit a separate form per medication; fax to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222; print/type or write legibly in blue or black ink
Include member weight with unit (lb or kg) for dosing calculations
Authorization does not guarantee payment and payment is subject to member eligibility. Providers must submit a separate completed prior authorization form for each medication; forms and all clinical documentation should be faxed to 1-866-240-8123 or mailed to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Incomplete submissions or missing clinical information may result in denial or delayed processing.
Coding & Supply
Provider Submission & Documentation Requirements
Incomplete submission risk
Incomplete or missing information on the prior authorization form or absent supporting clinical documentation may result in denial or processing delays. Payment remains subject to member eligibility and benefits; authorization does not guarantee payment.
- Ensure all fields on the form are complete and legible.
- Attach all required clinical records (see documentation callout).
- Allow adequate time for review — incomplete submissions will be returned or denied.
Administrative documentation required
Provide complete administrative/provider information with the submission. The prescribing physician (PCP or Specialist) should, in most cases, complete the form.
- Physician name, NPI, address (required for physician notification), phone and fax.
- Physician signature and date.
- Member identifying information (name, date of birth, member ID) and prescriber contact details.
- Submit a separate completed prior authorization form for each medication.
Prior therapy / step therapy documentation
Document prior therapy and step-therapy history demonstrating therapeutic failure, intolerance, or contraindication to applicable conventional therapies as required.
- List all prior therapies tried and the reason for failure (e.g., lack of efficacy, adverse reaction, intolerance).
- Common therapies to document include methotrexate, leflunomide, sulfasalazine, cyclosporine, hydroxychloroquine, phototherapy (PUVA/UVB), azathioprine, NSAIDs, local glucocorticoid injection, mercaptopurine, systemic corticosteroids (e.g., prednisone), and others as clinically relevant.
- Include dates/duration of prior therapies and any supporting clinical notes or lab results.
Background
This form is used to request prior authorization for specialty and disease-modifying medications typically prescribed by specialists (for example, rheumatologists, dermatologists, ophthalmologists, and immunologists). It collects clinical details needed for authorization decisions, including prior therapy history (step-therapy items), whether induction dosing is required, current therapy status and response, diagnosis/ICD-10 code(s), and member weight for dose calculations. The prescribing physician should, in most cases, complete the form and provide their full address for notification.
Revision History
Form instructions specify submission methods (fax to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222) and that a separate form is required for each medication, with legible completion in blue or black ink.
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