Pharmacy Prior Authorization Fax Form Form

CoverMyMeds is AzCH’s preferred way to receive prior authorization requests.
www.covermymeds.com/main/prior-authorization-forms/ to begin using this free service OR FAX this completed form to (833) 546-1508. Prior Authorization / Formulary Exception Request Fax Form CoverMyMeds is AzCH’s preferred way to receive prior authorization requests.
Visit www.covermymeds.com/main/prior-authorization-forms/ to begin using this free service OR FAX this completed form to (833) 546-1508. Form must be fully completed to avoid a processing delay For Prior Authorization Status Call: (866) 399-0928 Patient’s Name (Last, First, MI) -------------------
------------------- Date of Birth
MM / DD / YYYY
/ / Member ID # Please print clearly and enter one digit per box ------------
------------- Patient’s Phone Please print clearly and enter one digit per box -----------

----------- ( ) – Patient’s Address, City, State, Zip Gender M F Allergies Provider’s Name (Last, First, MI) Provider Specialty Contact Name Provider’s Address, City, State, Zip NPI # Provider’s Phone Please print clearly and enter one digit per box ------
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-------- Provider’s Fax Please print clearly and enter one digit per box ( ) – ( ) – Medication Name and Strength Quantity Direction for Use and Duration Diagnosis ICD-10 Code New Start with This Medication: Yes No If No, Date of First Dose Medications Previously Tried with Dates of Use (supporting documentation required) Medical Justification and Supporting Information (Chart Notes required. Labs required if applicable, Height and Weight) Patient Location for Administration: Doctor’s Office Infusion Suite Dialysis Center Home Outpatient Hospital Other (specify): *ALSO requests for medication to be covered by a non-par provider OR outpatient pharmacy for inpatient administration should be submitted to: Email: AZCH_PharmacyProviderLiaison@azcompletehealth.com Who will supply the drug? Provider’s Office (Buy/Bill) Dialysis Center Specialty Pharmacy Outpatient Hospital Pharmacy Retail Pharmacy Other (specify): Name of Provider/Facility/Pharmacy: (No response needed for retail pharmacies) Servicing Provider/Facility Information for injectable drugs only: Servicing Provider Servicing NPI: Contact Name: Name: Servicing TIN: Phone Number: Procedure Codes: Total Units/Visits/Days: Start Date: End Date: I certify that the above information is correct to the best of my knowledge. Physician’s Signature (required) Date The documents accompanying this facsimile transmission may contain information that is confidential and prohibited from disclosure. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of the information contained in this transmission is strictly prohibited. If you have received this transmission in error, please notify the sender immediately by telephone or by return FAX and destroy this transmission, along with any attachments. Mailing Address: Arizona Complete Health Pharmacy Department 333 E Wetmore, Suite 600 Tucson, AZ 85705 For copies of prior authorization forms and guidelines, please call (888) 788-4408 or visit the provider portal at www.AZCompleteHealth.com. Revised 07/01/2024