Prior Authorization : Forms and Attachments

Prior Authorization/Drug Attachment

When completing the PA/DGA form, prescribers should complete the most appropriate section as it pertains to the drug being requested. The specific sections are as follows:

• HealthCheck "Other Services" drug requests
• Diagnosis-restricted drug requests
• Drugs with specific PA criteria addressed in the ForwardHealth Online Handbook
• Other drug requests

Prescribers are required to fill out the appropriate section(s), then provide a handwritten signature and date on the PA/DGA form. Once completed, the prescriber should send the PA/DGA form to the pharmacy. The pharmacy should complete a PA/RF and submit it to ForwardHealth, along with the PA/DGA form from the prescriber.

Clinical Information for HealthCheck "Other Services" Drug Requests

If the prescriber writes a prescription for a drug that is not covered under the member's ForwardHealth benefit plan, the prescriber is required document the clinical rationale to support the medical necessity of the drug being requested as a HealthCheck "Other Services" PA request. Include documentation of the drug name, quantity, dose, duration of therapy, previous treatments, and detailed reasons why other covered drug treatments were discontinued or not used. Medical records and peer-reviewed medical literature should be provided as necessary to support the PA request. This information should be documented in Section IV (Clinical Information for HealthCheck "Other Services" Drug Requests) of the PA/DGA form.

When completing the PA/DGA form, prescribers should provide the diagnosis code and description, complete Section IV, and use Section VIII (Additional Information), if needed. Prescribers are reminded to provide a handwritten signature and date on the form before submitting it to the pharmacy provider where the prescription will be filled. The pharmacy provider is required to complete a PA/RF before submitting the PA/DGA form and supporting documentation to ForwardHealth. Prescribers should not submit the PA/DGA form to ForwardHealth.

Note: HealthCheck "Other Services" is limited to members under 21 years of age.

Clinical Information for Diagnosis-Restricted Drug Requests

If the prescriber writes a prescription with a diagnosis outside the ForwardHealth-allowed diagnoses for a drug, the prescriber is required to include peer-reviewed medical literature to support the proven efficacy and safety of the requested use of the drug. Documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not used are required. Medical records should be provided as necessary to support the PA request. This information should be documented in Section V (Clinical Information for Diagnosis-Restricted Drug Requests) of the PA/DGA form.

When completing the PA/DGA form, prescribers should provide the diagnosis code and description, complete Section V, and use Section VIII (Additional Information), if needed. Prescribers are reminded to provide a handwritten signature and date on the form before submitting it to the pharmacy provider where the prescription will be filled. The pharmacy provider is required to complete a PA/RF before submitting the forms and supporting documentation to ForwardHealth. Prescribers should not submit PA/DGA forms to ForwardHealth.

Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook

If a prescriber writes a prescription for one of the following drugs, a PA request must be submitted on the PA/DGA form:

• Abilify MyCite
• Agamree
• BBG drugs
• Bylavy
• Cayston
• Cholbam
• Cibinqo
• Crinone
• Cystic fibrosis drugs containing ivacaftor
• Cytokine and CAM antagonist drugs used to treat ERA, NMOSD, PMR, and SSc-ILD
• Dojolvi
• Dupixent
• Emflaza
• Emgality 100 mg
• Entadfi
• Glatopa
• Hemgenix
• Hetlioz and Hetlioz LQ
• Hypoglycemics, GLP-1 agents—combinations
• Imcivree
• Jesduvroq
• Jublia and tavaborole
• Jynarque
• Lipotropics, ACL inhibitor drugs
• Lipotropics, apo-B inhibitor drugs
• Livmarli
• Long-term HAE prophylactic drugs
• Luxturna
• Methamphetamine
• Misoprostol
• Nucala
• Opzelura (for vitiligo)
• Oxbryta
• Palynziq
• Rinvoq (for moderate to severe atopic dermatitis)
• Roctavian
• SMA Drugs
• Strensiq
• Teriparatide (generic Bonsity)
• Tezspire
• Tobi Podhaler
• Velsipity (for ulcerative colitis)
• Vigadrone
• Voquenza
• Voxzogo
• Vyjuvek
• Zeposia (for ulcerative colitis)

This information should be documented using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

When completing the PA/DGA form, prescribers should provide the diagnosis code and description, complete Section VI, and use Section VIII (Additional Information), if needed. Prescribers are reminded to provide a handwritten signature and date on the form before submitting it to the pharmacy provider where the prescription will be filled. The pharmacy provider is required to complete a PA/RF before submitting the forms and supporting documentation to ForwardHealth. Prescribers should not submit PA/DGA forms to ForwardHealth.

Clinical Information for Other Drug Requests

If the prescriber writes a prescription for a drug that requires the use of the PA/DGA form and has not been previously referenced in the above PA/DGA sections, the prescriber is required to document the clinical rationale to support the medical necessity of the drug being requested. Documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not used are required. In addition, if the drug requested is a non-preferred PDL drug, prescribers are required to specifically address why other preferred PDL drugs cannot be used. Medical records and peer-reviewed medical literature should be provided as necessary to support the PA request. This information should be documented in Section VII (Clinical Information for Other Drug Requests) of the PA/DGA form.

If the pharmacy submitting the PA request is an out-of-state pharmacy providing a non-emergency service and the drug being requested does not have specific PA criteria established, additional documentation is required to be submitted. PA request documentation must demonstrate that the member has a medical condition for which the requested drug has FDA approval (medical records must be provided to verify the member's medical condition). Additionally, the drug must be prescribed in a dose and manner consistent with the FDA-approved product labeling.

When completing the PA/DGA form, prescribers should provide the diagnosis code and description, complete Section VII, and use Section VIII (Additional Information), if needed. Prescribers are reminded to provide a handwritten signature and date on the form before submitting it to the pharmacy provider where the prescription will be filled. The pharmacy provider is required to complete a PA/RF before submitting the forms and supporting documentation to ForwardHealth. Prescribers should not submit PA/DGA forms to ForwardHealth.

Prescribers and pharmacy providers are required to retain a completed copy of the PA request form(s).

Note: For assistance in identifying PDL drugs that require completion of Section VI and Section VII of the PA/DGA form, providers may refer to the Preferred Drug List Quick Reference.