UPMC Health Plan | For Providers | Prescription Prior Authorization Forms

PROVIDERS

Pharmacy Prior Authorization Forms

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Notice: RSV season is in full swing. If you are submitting a PA form for Synagis, it is important that you submit UPMC Health Plan's Synagis PA form (available below). Other Synagis PA forms require different criteria. Using another form could delay our review.

If you require a prior authorization for a medication not listed here, please contact UPMC Health Plan Pharmacy Services at 1-800-396-4139. UPMC Health Plan makes all decisions on prior authorization requests within 24 hours from the time of initial review.

Our Prior Authorization process has been enhanced to better serve you. Read our frequently asked questions to get answers to questions that can arise around the Prior Authorization process.

Prior Authorization Process:
UPMC Health Plan makes all decisions on prior authorization requests within 24 hours from the time of initial review. The Health Plan occasionally requires additional information when completing a clinical review. If additional information is required, we will fax a letter to your office that details what additional information is needed.

The requested information must be received within 24 hours of the original prior authorization request, or the request will be denied due to lack of sufficient information for review. The Health Plan will notify you of its prior authorization decision via fax on the date the actual decision is made. If your office is unable to receive faxes, you will be notified via U.S. mail.

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These forms serve all UPMC Health Plan products unless specified otherwise.