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Prior Authorization for Medication
Request for insurance approval before prescribing a medication that requires prior authorization under the patient's health plan.
PDF TemplateUse the instructions below to complete this form
Instructions
Include the patient's insurance information, diagnosis codes (ICD-10), the medication name, dose, and duration. Provide clinical justification explaining why the requested medication is medically necessary and why formulary alternatives are inadequate. Attach supporting documentation such as lab results or clinical notes. Insurers must respond within 72 hours for non-urgent requests and 24 hours for urgent requests.