Prior Authorization Forms

Partnership HealthPlan Prior Authorization Forms, for MEDICAL Benefit Claims:

The forms included below are only for claims to be billed as medical claims direct to PHC. This includes drugs to be administered directly to a member by a medical healthcare provider (hospitals, surgery centers, prescriber offices, and clinics). A separate form is available for non-drug per diem codes allowed for infusion pharmacies.

•  MEDICAL Benefit Drugs: TAR form for HCPCS/CPT/NDC Codes for Prescriber Administered Drugs (PADs)

• Infusion Pharmacy Per Diem Services: TAR form for CPT PER DIEM codes

Medi-Cal Rx (Pharmacy TARs): 

• State Medi-Cal Rx Prior Authorization Flyer (Five Ways to Submit a Prior Authorization (PA)
• State Medi-Cal Rx Provider Portal
• State Medi-Cal Rx Pharmacy Services TAR Form