Upmc Auth Form PDF Details

In navigating the complexities of medication approval, the UPMC Auth Form stands out as a key document, especially for drugs like POTIGA and VIMPAT, which require prior authorization. The urgency of obtaining medication quickly for some patients is recognized, providing a direct contact option for urgent requests which underscores the form's role in streamlining the process. The form mandates the inclusion of comprehensive details, including past medical treatments and justifications for the need for an exception, highlighting a thorough approach to patient care. It emphasizes accurate and neat information input to avoid delays, showcasing the importance of clarity in medical communications. With sections dedicated to the provider’s contact and specialty information, patient identification, and specifics about the medication requested, such as whether the drug is brand name or generic, it's designed to ensure all relevant details are accessible. This approach not only aids in substituting generic equivalents where possible but also helps in tracking the medication's efficacy over time. Additional information regarding the patient's diagnosis, medical history, and any previous trials of related medications is required, underlining the personalized and cautious approach adopted towards prescription practices. This comprehensive form serves as a bridge between healthcare providers and pharmacy services, ensuring that patients receive the most appropriate medication based on their unique health profiles and past treatment responses.

QuestionAnswer
Form NameUpmc Auth Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesupmc for you prior auth form pdf, upmc authorization form, upmc prior authorizations, upmc prior auth form

Form Preview Example

POTIGA, VIMPAT

Prior Authorization Form

IF THIS IS AN URGENT REQUEST, Please Call UPMC Health Plan Pharmacy Services.

 

Otherwise please return completed form to:

 

UPMC HEALTH PLAN PHARMACY SERVICES

PHONE 800-979-UPMC (8762)

FAX 412-454-7722

PLEASE TYPE OR PRINT NEATLY

Please complete all sections of this form AND include details of past relevant medical treatment, which substantiates the need for an exception to using formulary alternatives, i.e. past prescription treatment failures, documented side effects, chart documentation, lab values, etc. Incomplete responses may delay this request.

Office Contact:

Provider Specialty:

Provider First Name:

Provider Last Name:

Provider Phone:

Provider Fax:

Provider NPI #:

Patient Name:

Patient UPMC Health Plan ID Number:

Patient DOB:

Patient

Age:

Drug Requested:

฀Brand ฀Generic

Strength:

Frequency:

Qty Dispensed:

Generic equivalent drugs will be substituted for Brand name drugs unless you specifically indicate otherwise.

฀New medication

฀Ongoing medication

If ongoing, provide date started:

If medication is ongoing, Did member Show improvement while on therapy?

฀Yes ฀No

Diagnosis:

Date of diagnosis:

Medical History

Does the member have a diagnosis of partial-onset seizures? ฀Yes ฀No

Please list other anti-epileptic drugs the member is currently taking in the space below.

Medication Trial

Date of Therapy

Start Date

End Date

Strength

Frequency

List adverse reactions/side

effects/reason for discontinuing

Please provide any additional information which should be considered in the space below:

Potiga, Vimpat PA form

All PA forms available at www.upmchealthplan.com/providers/pa_forms.html

July 2012

How to Edit Upmc Auth Form Online for Free

We were designing this PDF editor having the notion of allowing it to be as quick to use as possible. That's the reason the procedure of managing the prema prior auth forms will undoubtedly be smooth follow these steps:

Step 1: Get the button "Get Form Here" and click it.

Step 2: So you should be within the document edit page. You can include, adjust, highlight, check, cross, insert or delete areas or text.

The following sections are what you will have to fill out to get your finished PDF file.

example of gaps in upmc medication prior auth form

Write down the data in the Medication Trial, Date of Therapy, Start Date, End Date, Strength, Frequency, List adverse reactionsside, Please provide any additional, Potiga Vimpat PA form, All PA forms available at, and July field.

upmc medication prior auth form Medication Trial, Date of Therapy, Start Date, End Date, Strength, Frequency, List adverse reactionsside, Please provide any additional, Potiga Vimpat PA form, All PA forms available at, and July blanks to fill

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Step 4: Come up with around two or three copies of the file to keep clear of any specific upcoming troubles.

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