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providers Pharmacy Prior Authorization Forms

If you require a prior authorization for a medication not listed here, please contact UPMC Health Plan Pharmacy Services at 1-800-979-UPMC (8762)*. 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.

*If you are unable to locate a specific drug on our formulary, you can also select Non-Formulary Medications, then complete and submit that prior authorization form.

Medicare Prescription Drug Determination Request Forms

Prescribing physicians can fill out the following form to request a prescription drug exception for UPMC for Life members. There are two ways you can submit this form to us.

Online:

  1. Please follow these steps to submit a prescription drug determination request form to us.
    Select and open the form.

    UPMC for Life Prescription Drug Coverage Determination/Exception Request Form

  2. Fill out the form and save the form to your computer's hard drive.

    Please note:

    • If you upload this file to us, it will remain on your computer.
    • If you are using a public or shared computer and you do not want to save your personal health information on that computer, you should consider calling Member Services or print and mail the form.
  3. Click here to submit the form to us.

Print and Fax:

Open the form you wish to fill out. Print the form. Fill it out and fax it to us using the instructions provided on the form.
Fax: 412-454-7722

The Medicare program offers forms to Medicare providers for prescription drug determination. Use the following link below to view this information on the Medicare website.

Medicare Part D Coverage Determination Request Form

 

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