Prior Authorization : Forms and Attachments

Prior Authorization/Physician-Administered Drug Attachment

Individual sections on the PA/PAD form identify specific types of physician-administered drug PA requests that require clinical PA, and ForwardHealth has defined criteria for those sections. Prescribers must submit the PA/PAD form along with the PA/RF to request PA.

When completing the PA/PAD form, prescribers must complete the most appropriate section as it pertains to the physician-administered drug being requested. The specific sections are as follows:

• Clinical information for diagnosis-restricted physician-administered drug requests
• Clinical information for physician-administered drugs with specific PA criteria addressed in the ForwardHealth Online Handbook
• Clinical information for other physician-administered drug requests
• Additional information (Prescribers should complete this section if more space is needed on the PA/PAD form, or the prescriber is including additional information.)

Prescribers must fill out the appropriate section(s), then sign and date the PA/PAD form.

PA requests for physician-administered drugs must be completed, signed, and dated by the prescriber. PA requests for physician-administered drugs must be submitted using the PA/PAD form. Clinical documentation supporting the use of a physician-administered drug must be submitted with the PA request.

Prescribers are required to submit the completed PA/PAD form and a completed PA/RF to ForwardHealth.

PA requests for physician-administered drugs may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Prescribers are reminded that they are required to complete, sign, and date each PA form when submitting the PA request. Prescribers are required to retain a completed copy of the PA request form(s).

Clinical Information for Diagnosis-Restricted Physician-Administered Drug Requests

If the prescriber orders a drug that is a physician-administered drug with a diagnosis outside the ForwardHealth-allowed diagnoses, the prescriber must submit peer-reviewed medical literature to support the proven efficacy and safety of the requested use of the physician-administered drug. Prescribers must also include documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not used. Medical records should be provided as necessary to support the PA request.

This information should be documented in Section IV (Clinical Information for Diagnosis-Restricted Physician-Administered Drug Requests) of the PA/PAD form.

When completing the PA/PAD form, prescribers should provide the diagnosis code and description, complete Section IV, and use Section VII (Additional Information) if needed. Prescribers are reminded to sign and date the form before submitting the PA/PAD form and the PA/RF to ForwardHealth. Clinical documentation supporting the use of the physician-administered drug must be submitted with the PA request.

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

If the prescriber orders one of the following drugs, a PA request must be submitted on the PA/PAD form:

• Leqvio
• OnabotulinumtoxinA (Botox) (Note: The PA/PAD form must be submitted for a PA request if the prescriber is ordering Botox for a member in a manner that is not consistent with the guidance provided in the Online Handbook.)
• Skyrizi IV
• Stelara IV

This information should be documented using Section V (Clinical Information for Physician-Administered Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/PAD form. Prescribers should refer to the appropriate topic in the Online Handbook for the drug-specific clinical PA criteria.

When completing the PA/PAD form, prescribers should provide the diagnosis code and description, complete Section V, and use Section VII (Additional Information) if needed. Prescribers are reminded to sign and date the form before submitting the PA/PAD with the PA/RF to ForwardHealth. Clinical documentation supporting the use of the physician-administered drug must be submitted with the PA request.

Clinical Information for Other Physician-Administered Drug Requests

If the prescriber orders a drug that is a physician-administered drug that requires the use of the PA/PAD form and has not been previously referenced in the above PA/PAD sections, the prescriber must document the clinical rationale to support the medical necessity of the physician-administered drug being requested. Documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not used is required. Medical records and peer-reviewed medical literature should be provided as necessary to support the PA request.

PA 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.

This information should be documented in Section VI (Clinical Information for Other Physician-Administered Drug Requests) of the PA/PAD form.

When completing the PA/PAD form, prescribers should provide the diagnosis code and description, complete Section VI, and use Section VII (Additional Information) if needed. Prescribers are reminded to sign and date the form before submitting the PA/PAD form with the PA/RF to ForwardHealth. Clinical documentation supporting the use of the physician-administered drug must be submitted with the PA request.

Additional Information

Additional diagnostic and clinical information explaining the need for the drug requested may be included in Section VII of the PA/PAD form. If the space provided in the other sections is not sufficient, additional information may be included here.