Prior Authorization Request Form — Drug Benefit (including SUD medications)
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This document is a SelectHealth prior authorization request form for prescription drug benefits, including requests for medications to treat substance use disorders; it governs submission requirements for providers and pharmacies seeking prior authorization or reauthorization.
No material clinical or coverage changes in this revision.
Coverage criteria & SUD prior-auth guidance
Authorization and approval criteria
Form submission and approval elements
Supported by form fields in document
Form checkboxes for New Request/Reauthorization
Legal/coverage note included on form
No prior authorization may be imposed for FDA‑approved prescription medications on the carrier’s formulary that are approved to treat substance use disorders. This legal requirement has been in effect since January 1, 2020 and supersedes any prior authorization requirement that would otherwise apply to such formulary SUD medications.
When completing a drug prior authorization request for a medication used to treat a substance use disorder, providers should note whether the drug is being prescribed for SUD on the form. If the drug is an FDA‑approved SUD medication and it appears on the carrier’s formulary, the carrier may not require prior authorization under this policy statement; for all other medications and indications, follow the standard prior authorization submission and documentation requirements on the form.
Requested drug codes
| J-Code if applicable | J-Code for administered drugs (document requests inclusion if applicable) |
Provider submission requirements and important notes
Prior Authorization Required
Prior authorization is required for new requests and reauthorizations unless the medication is an FDA‑approved SUD treatment listed on the carrier's formulary (per state rule effective Jan 1, 2020). Complete and submit the prior authorization form with all required details to support approval.
- Submit completed prior authorization form including patient and prescriber information, diagnosis ICD‑10 code(s), drug name(s) and J‑codes (if applicable), strength/route/frequency, quantity/volume, start date and length of therapy, location of treatment (with Type 2 NPI and tax ID when applicable), dispensing pharmacy name and phone number, prescriber signature and date.
- Provide clinical criteria for approval: clinical rationale, other pertinent information, and a complete medication history — list other medications tried, their names, durations, and the patient’s response to each to support step‑therapy or failure documentation.
- Indicate whether this is a New Request or Reauthorization.
- If the drug is being prescribed to treat a substance use disorder, note this on the form; do not apply PA requirements to FDA‑approved SUD medications on the formulary per the SUD PA prohibition.
- If the request is urgent, mark the form accordingly and include justification that waiting could seriously jeopardize life or health.
Denial follow‑up — provide reason and alternatives
When a prior authorization decision results in denial, the form requests the reason for denial and requests that the reviewer include alternative formulary medications when applicable. Use this information to determine next steps (appeal, select alternative therapy, or resubmit with additional documentation).
- If denied, document the reason for denial on the form.
- If denied, list alternative formulary medications suggested by the reviewer, if any, to guide subsequent prescribing or appeals.
Submission checklist
Checklist — ensure the submission includes all items requested on the form to avoid delays or denials.
- Patient and prescriber identifying information (name, DOB, member/subscriber number, contact details, prescriber NPI/DEA/Tax ID).
- Diagnosis and ICD‑10 code(s).
- Drug name (brand and scientific), strength, route, frequency, quantity, number of refills, and J‑code if applicable.
- Start date and length of therapy, location of treatment and facility identifiers when applicable.
- Complete medication history: other medications tried, duration of therapy for each, and patient response.
- Supporting clinical documentation and prescriber signature/date.
New request (Initial authorization) criteria
Initial authorization
New Request
Form fields captured in document
Reauthorization / continuation criteria
Reauthorization
Reauthorization
Form includes checkbox for Reauthorization
Prior medication history / step therapy documentation
| Medication | Duration | Patient response |
|---|---|---|
| [form field] Other medications tried (list names) | [form field] Duration of each medication tried | [form field] Patient response to each medication (e.g., improved, no response, intolerable side effects) |
Treatment location information
Provide location of treatment and identifiers
Specify the site of care on the form (for example: provider office, facility, or home health) and include the site name, Type 2 NPI if applicable, full address, and contact information.
- Site name
- Type 2 NPI (if applicable)
- Full address
- Contact phone/fax
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