AmeriHealth Caritas (DE)Commercial Clinical Policy

Universal Pharmacy Form Form

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Universal Pharmacy Form

Indications

(1) Is the requested option Brand Medically Necessary request (Rationale required below) Directions: Quantity Requested: Anticipated Length of Therapy:? 
(2) Is this a chronic condition? □ Yes □ No? 

Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



Universal Pharmacy Prior Authorization Form

Confidential Information

Patient Name

Patient DOB Patient ID Number Prescriber Name Specialty Prescriber Phone ( ) Prescriber Fax ( ) NPI# Prescriber Address City State Zip Medication Name and Strength Requested:

□ Brand Medically Necessary request (Rationale required below) Directions:
Quantity Requested: Anticipated Length of Therapy:

□ ___ Days □ 3 Months □ 6 Months □ 12 Months

Diagnosis: Is this a chronic condition? □ Yes □ No Preferred Medications tried/previous therapy, please include strength, frequency and duration:

Rationale and/or additional information, which may be relevant to the review of this prior authorization request:

Prescriber Signature Date

PerformRx
200 Stevens Drive Philadelphia, PA 19113

Please fax this form to: 855-829-2872 PerformRx Provider Services:
Phone: 855-251-0966

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