Before submitting a Prescription Drug Prior Authorization Request (PAR) Form, search HPSM’s formulary for the drug you want to prescribe. Make sure you search the formulary for the member’s specific health plan.
- If the drug you searched is in the formulary, you do not need to submit the authorization form.
- If the drug you searched is not in the formulary or has the initials NF, PA, QL or ST next to it, then complete the Prescription Drug PAR Form and fax it to HPSM at 650-829-2045.
Download the Prescription Drug Prior Authorization Request Form
Required Clinical Information
- Lab results with dates and/or justification for initial or ongoing therapy or increased dose
- Lab results with dates must be provided if needed to establish diagnosis or evaluate response
- Information on whether the patient has any contraindications for the health plan/insurer preferred drug
- Any additional clinical information or comments pertinent to this request for coverage (e.g. formulary tier exceptions) or required under state and federal laws
If you have any questions about the Prescription Drug PAR Form, please call HPSM’s Pharmacy Services at 650-616-2088.
CareAdvantage Coverage Limitations and Exceptions
Prior Authorization Criteria (PA)
These drugs are in the CareAdvantage Formulary but need to be pre-approved before you fill a prescription. This also includes the criteria for approval of each drug.
Quantity Limits (QL)
These drugs are covered but have a set limit on the amount of pills per prescription and the number of times they can be refilled without further authorization.
Step Therapy Criteria (ST)
Some drugs are covered only after you have a tried a recommended drug, but it did not work. When there are two drugs for your condition, CareAdvantage may require you to try one drug first before covering the other drug.
Pharmacy Authorization Forms
Pharmacy Authorization Fax Numbers
Prescription drug prior authorization:
Incontinence supply authorization: