Medical Prior Authorization and Physician Forms

Pharmacy Prior Authorization

Providers may submit prior authorization requests to UPMC Health Plan online or by fax.

  • To submit a request online, please visit UPMC's PromptPA Portal.
  • To submit a request via fax, please select the appropriate form below. These forms serve all UPMC Health Plan products unless specified otherwise.
  • UPMC Health Plan also accepts requests via electronic Prior Authorization (ePA) for those providers that have EMRs enabled to submit ePA requests through Surescripts. Please note that Surescripts or other ePA portals are third-party platforms not controlled by UPMC Health Plan, and UPMC Health Plan cannot be held responsible for technical issues arising from a provider's use of such third-party platforms.

We occasionally require 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.

If the requested information is not received back in a timely manner 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.

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).

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.

Peer-to-peer discussions

Medical directors are available to discuss denials based on medical necessity. Providers can reach them by calling the Pharmacy Services Department at 1-800-979-UPMC (8762). The medical directors are available during and after normal business hours (subject to reasonable limitations of availability). Adverse benefit determinations can be discussed from the time of denial until the internal grievance process or internal adverse benefit determination process commences.

 

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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:

  1. Online
    Select and open this form: UPMC for Life Prescription Drug Coverage Determination/Exception Request Form

    Fill out the form and save the form to your computer's hard drive. Then, submit the form online.

    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, consider calling Member Services or print and mail the form.
  2. 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 to view this information on the Medicare website: Medicare Part D Coverage Determination Request Form