UPMC Health Plan requires a prior authorization request for specific procedures or treatments to determine whether coverage of a request will be approved or denied.

Get fast, easy access to downloadable forms. Download medical prior authorization forms here. Download pharmacy prior authorization forms here. Download NOMNC Forms here. These forms are for Skilled Nursing Facilities, Comprehensive Outpatient Rehabilitation Facilities, and Home Health Providers.

Before you get started, in addition to your insurance card, you will need the following information. This information can be obtained by contacting your prescribing physician.

Please complete all sections of this form AND include details of past relevant medical treatment, which substantiates the need for an exception to using formulary alternatives, i.e. past prescription treatment failures, documented side effects, chart documentation, lab values, etc.

If a form for the specific medication cannot be found, please use the Global Prior Authorization Form. California members please use the California Global PA Form. To access other state specific forms, please click here.

As a convenience to patients, the following links provide access to many commonly-used governmental forms. All forms are PDF files. UPMC Forms. 2019-2020 Parent-Guardian Release Form – Family Health Center Free Inhaler Program; Consent for Treatment, Payment and Health Care Operations; Personal Representative Designation; Medical Consent ...

Prior Authorization Form for UPMC for Life, UPMC for You Advantage, UPMC for Life Options, and UPMC for Community Care Medicare Members IF THIS IS AN URGENT REQUEST, please call UPMC Health Plan Pharmacy Services.

Optum Rx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations. Visit go.covermymeds.com/OptumRx to begin using this free service. Please note: All information below is required to process this request. Mon-Fri: 5am to 10pm Pacific / Sat: 6am to 3pm Pacific .

Opioid-related prior authorization request forms: Opioid treatment information. Pharmacy prior authorizations are required for pharmaceuticals that are not in the formulary, not normally covered, or which have been indicated as requiring prior authorization.

For a beneficiary who has received opioid treatment for the past 3 months: Has results of a recent urine drug screen (UDS) testing for licit and illicit drugs with the potential for abuse, including specific testing for oxycodone, fentanyl,