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Description of restat prior authorization form
Date PRIOR AUTHORIZATION FORM M. D. Last Name Physician Phone M. D. First Name Physician Fax Patient ID DOB TO ENSURE PROMPT PROCESSING PLEASE COMPLETE ALL OF THE QUESTIONS. Complete the following for the drug requested Drug name Strength SIG Length of Therapy Disease State Diagnosis Code Chart notes are required to document failure from the physician in order to override the benefit. Treatment / Drug Used Date s...
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Let's walk through an example of an EPA request that requires additional information on your part in order to complete the process double click on the to do list notification to open the EPA status dialogue remember you can also right-click on the medication name from the face sheet and select open EPA status dialog to get here as well if you would like to cancel this EPA request you will have the option to do so from this dialog by clicking cancel process to address the prior authorization questions click the link for complete PA form located to the right of action required you will then be taken to a summary screen where you will click star in order to begin the process then answer each question and click Next to proceed if you would like to go back to the previous screen click back if you would like to cancel your answer to this question and go back to the previous screen then click release if you would like to save your answers and finish later click save on any of the screens otherwise click Submit to send your answers to the PBM you will then be taken to the process history for this request if you would like to review the information you just submitted click the call out next to complete PA form to do so when you are done viewing the EPA request click the red X in the upper right corner to close the EPA status dialogue at this point you may also want to delete the to do list notification regarding the status change for this EPA request which is done by highlighting the message and clicking delete

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