CurrentSelectHealthPolicy N/A

Prior Authorization Request Form — Drug Benefit (including SUD medications)

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.

Policy Summary

PayerSelectHealth

PolicyPrior Authorization Request Form — Drug Benefit (including SUD medications)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with patient and prescriber details, diagnosis (ICD code), drug information (with J‑Code if applicable), treatment location, prior medication history, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form type

2020-01-01SUD prior auth reference

800-538-5038contact phone

801-650-3279fax

Coverage criteria & SUD prior-auth guidance

Authorization and approval criteria

Form submission and approval elements

Form completion requirements: Submit completed form with patient and prescriber identifiers, diagnosis and ICD code(s), drug(s) requested (with J-Code if applicable), strength/route/frequency, quantity/volume, start date and length of therapy, location of treatment (including name, Type 2 NPI if applicable, address and tax ID), clinical criteria including other medications tried with duration and patient response, and prescriber signature.

Supported by form fields in document

Request type: Request may be New Request or Reauthorization as indicated on the form.

Form checkboxes for New Request/Reauthorization

SUD medication prior authorization exception: 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.

Policy Summary

PayerSelectHealth

PolicyPrior Authorization Request Form — Drug Benefit (including SUD medications)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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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.

Provider submission requirements and important notes

Prior Authorization

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 Risk

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.

Documentation Required

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.

OpenPayer

Prior Authorization Request Form — Drug Benefit (including SUD medications)

Coverage criteria & SUD prior-auth guidance

Requested drug codes

Provider submission requirements and important notes

New request (Initial authorization) criteria

Reauthorization / continuation criteria

Prior medication history / step therapy documentation

Treatment location information