Prescribers use this one-page form to request prior authorization for outpatient drugs under the Health First Colorado fee-for-service pharmacy benefit. It collects patient and prescriber details, including NPI and DEA numbers, the drug, strength, quantity and dosing frequency, diagnosis and method of diagnosis, failed medications, contraindications, current medications, dated labs, medical justification and where the drug will be given.
The prescriber completes the form. The prescriber or an authorized requestor acting for the prescriber must sign, confirming that the criteria information is accurate and verifiable in patient records.
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Prior Authorization Form (Health First Colorado Pharmacy)
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The prescriber or an authorized requestor signing on the prescriber's behalf. The signature line is required, and by signing the prescriber confirms that the criteria information on the form is accurate and verifiable in the patient's records.
Yes. Prescribers can submit electronic prior authorization requests through their EHR system or the CoverMyMeds provider portal, fax the form, or call the PA Help Desk, which is open 24 hours a day, seven days a week.
In the Preferred Drug List and Appendix P, the Pharmacy Benefit Prior Authorization Procedures and Criteria, both posted on the Pharmacy Resources page. The form itself points prescribers to them and warns that requests lacking required information face delays.