Prior Authorization Request – Injectable Medication

This PDF contains a Prior Authorization Request form specifically designed for injectable medications. It provides detailed fields for patient information, authorization details, prescriber information, and medical rationale. The form must be completed and faxed to Pharmacy Services for processing. It emphasizes the need for correct J-Codes to expedite requests and outlines requirements for relevant medical documentation. This form is explicitly for requests to be administered in a healthcare provider’s office and not for self-administration at home.