Colorado's Division of Insurance requires health insurance carriers and the pharmacy benefit managers working for them to accept one standard form for prescription drug prior authorization, including step therapy and non-formulary exception requests. Prescribers meet it whenever a Colorado-regulated plan needs approval before covering a drug. The template sits in Appendix A of Regulation 4-2-49, and each carrier publishes a branded copy that routes the request to its own reviewers.
The prescribing provider completes the entire form, from the patient and prescriber information through the medication requested, the clinical criteria and the signature.
Download the current version from the source each time; forms change without notice.
Uniform Pharmacy Prior Authorization Request Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. Under Division of Insurance Regulation 4-2-49, carriers and the pharmacy benefit managers acting for them must use this standard form for prescription drug prior authorization requests in Colorado, including step therapy and non-formulary exception requests. Each carrier posts its own branded copy of the Appendix A template with its routing details.
No. The Division of Insurance regulation governs commercial carriers and their PBMs. Colorado Medicaid pharmacy prior authorization uses a separate form from the Department of Health Care Policy and Financing, so check which coverage the patient has before choosing the form.
The version adopted in amended Regulation 4-2-49, effective January 1, 2026. The form first appeared in 2014 and was amended in 2019. Some carrier copies print the effective date on the page, such as 'Effective 1-1-26', which helps confirm the copy is current.