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PRIOR AUTHORIZATION / DRUG ATTACHMENT (PA/DGA)
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F-11049 (07/2016)
SECTION VI – CLINICAL INFORMATION FOR DRUGS WITH SPECIFIC CRITERIA ADDRESSED IN THE FORWARDHEALTH
ONLINE HANDBOOK
16. Review the ForwardHealth Online Handbook PA criteria on the ForwardHealth Portal and document the required information.
Refer to the Prior Authorization Drug Attachment topic in the Prior Authorization section of the Online Handbook for more
information and a list of drugs.
SECTION VII – CLINICAL INFORMATION FOR OTHER DRUG REQUESTS
17. 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 is required. In addition, if the
drug requested is a non-preferred PDL drug, 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.
Note: 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. Prior
authorization documentation must demonstrate that the member has a medical condition for which the requested drug has Food
and Drug Administration (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.
Continued

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