Arizona Complete Health Specialty Pharmacy PA: Required Fields, Attachments, and Routing
- Jamie P
- Sep 15
- 8 min read
When a pharmacist tells you “PA required,” the clock starts. For Arizona Complete Health (Medicaid/Marketplace) members, specialty drugs often require pharmacy prior authorization (PA) before the plan will cover the medication—sometimes with a designated specialty pharmacy for dispensing. The difference between a smooth two–five business day turnaround and a multi-week stall usually comes down to three things: completing every required field the way the reviewer expects, attaching the right clinical evidence (not the whole chart), and choosing the correct routing channel (ePA/portal > fax) with the proper specialty-pharmacy handoff.
This playbook explains how to submit one-and-done specialty medication PAs for Arizona Complete Health (AzCH) members. You’ll get a precise field-by-field checklist, attachment and step-therapy templates, routing guidance for Medicaid vs. Marketplace products, real-world scripts, and a tight follow-up cadence to prevent stalls. Keep it handy as an SOP for your team.
What “Specialty Pharmacy PA” Means And Why It’s Different
Specialty medications—biologics, injectables, limited-distribution therapies, and high-cost oral agents—carry extra rules for coverage and dispensing. A clean AzCH PA packet for these drugs does four things:
Proves medical necessity for the drug and regimen (diagnosis, severity, phenotype, risk).
Documents step therapy or formulary exception rationale with names, dates, adherence, outcomes, and adverse events—not just “tried/failed.”
Shows safety readiness (baseline labs/screens) and a monitoring plan.
Routes correctly to the plan’s pharmacy benefit and, once approved, to the required specialty pharmacy—so dispensing doesn’t stall after the PA decision.
Because AzCH operates multiple product lines (e.g., Medicaid under AHCCCS and Marketplace plans branded Ambetter from Arizona Complete Health), the forms, portals, and vendors can differ. The member ID card and plan portal tell you which lane to use. When in doubt, check the plan portal first and use electronic prior authorization (ePA).
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Choose the Correct Lane Before You Type a Single Word
Confirm benefit and product. Is the medication billed under the pharmacy benefit (NDC at a retail or specialty pharmacy)? If yes, you’re in the pharmacy PA lane—not medical “buy-and-bill” J-codes. Note whether the member is Medicaid (AHCCCS) or Marketplace (Ambetter).
Use the portal/ePA first. AzCH supports portal-based PA and connected ePA workflows that present plan-specific questions in the right order and force the required fields—which reduces pended cases. Use fax only if the portal doesn’t support the request type or if the system is down.
Check specialty-pharmacy rules. Many specialty medications must be dispensed by a designated specialty pharmacy once approved. Align your eRx destination to plan rules so the first fill doesn’t bounce.
Keep product differences in mind. Marketplace (Ambetter) and Medicaid (AzCH-Complete Care Plan) may use different forms, modes, or vendor workflows for certain categories (e.g., oncology). Submit in the product-specific channel the ID card/portal directs you to.
The Required Fields Reviewers Expect (Fill These Exactly)
Think like a reviewer: you have minutes to decide whether the request meets policy criteria. Make approval easy by structuring your submission exactly the same way every time.
Member & Plan
Full name (as on the ID), DOB, member ID
Product/line of business (e.g., Medicaid vs. Marketplace)
Best patient phone and email (so the specialty pharmacy can schedule delivery quickly)
Prescriber & Site
Prescriber name, NPI, TIN, specialty, contact phone/fax
Clinic address and after-hours contact (for safety questions)
Medication & Regimen
Drug name, strength, dosage form, route
Quantity per fill and days’ supply (e.g., “2 pens every 28 days”)
Dosing/titration plan and expected duration
Dispense As Written (if clinically necessary) with the reason (e.g., device compatibility)
NDC (some plan flows require it; use the NDC that matches your eRx)
Diagnosis & Severity
ICD-10 code(s) that match the requested indication
One short paragraph on severity and function (e.g., ADL limits, validated scores, hospitalization risk)
Step Therapy / Formulary Exception
Document each prior agent in a uniform, scannable format:
Drug name and dose
Start/stop dates (approximate is fine: “2025-02 to 2025-04”)
Adherence (e.g., “~85% of doses over 6 weeks”)
Outcome measure (e.g., migraine days/month, PASI, FEV1, A1c)
Adverse events with onset/resolution
Reason for discontinuation (ineffective, intolerance, contraindication)
If asking for a formulary or step-therapy exception, state plainly why the plan-preferred drug is unsafe, already failed, or clinically inappropriate for this patient—and back it with objective data.
Safety & Monitoring
List baseline and monitoring requirements with dates and values, then attach the reports:
Infectious disease screens (e.g., TB, hepatitis) for immunomodulators
Organ function labs (AST/ALT, SCr/eGFR)
Pregnancy status where relevant
EKG/echo or class-specific tests when indicated
REMS or program enrollment, if applicable
Follow-up cadence and stop rules (when you’ll deprescribe or switch)
Routing & Dispensing
Identify the specialty pharmacy if required and match your eRx destination to it.
Add any delivery constraints (cold-chain, injection teaching appointment date).
The One-Page Medical-Necessity Summary
Use this as your PA cover note inside the portal/ePA or as a first page in your packet:
Patient / Plan: [Name, DOB, Member ID, product (Medicaid/Ambetter)]
Medication & Regimen: [Drug, strength, route; quantity per fill; days’ supply; titration plan]
Diagnosis & Severity: [ICD-10] + function-forward snapshot (ADL limits, risk, validated score if useful)
Treatment History:
[Drug A] [dose] [mm/dd/yyyy–mm/dd/yyyy] — adherence ~[x%], outcome [metric], AE [if any], reason for stop
[Drug B] [dose] [mm/dd/yyyy–mm/dd/yyyy] — adherence ~[x%], outcome [metric], AE [if any], reason for stop
Safety & Monitoring: [TB/LFTs/eGFR/etc. with dates/values; REMS; monitoring cadence; stop rules]
Clinical Rationale: Why this medication now; phenotype/route fit; risk of delay
Routing Notes: [Portal/ePA confirmation ID; required specialty pharmacy; teach visit date]
Keep it one page. Make sure the dose/frequency match your eRx and any forms. Mismatches are the #1 pend trigger.
What To Attach: Evidence That Moves Decisions
Attach evidence, not the entire chart. Label files clearly so reviewers can spot exactly what they need.
Clinic note supporting diagnosis, severity, phenotype, and treatment history
Lab/diagnostic reports: include dates and values
Specialist consults when complexity spans disciplines
Immunization or pregnancy status docs when required for therapy class safety
Program enrollment confirmation for any REMS or specialty programs (if applicable)
Do not attach: full chart exports, scheduling messages, or duplicate PDFs with the same content under different names. Signal-to-noise matters.
Use ePA First—Here’s How To Make It Faster
Electronic prior authorization (ePA) inside your EHR or via a connected portal accelerates decisions by presenting plan-specific questions and forcing required fields. To get the most from ePA:
Build smart phrases (dot phrases) for step-therapy blocks, safety-lab summaries, and the one-page template.
Pre-map your top 10 specialty drugs: the usual baseline labs, monitoring cadence, and common exception reasons.
Always capture the submission/confirmation ID and paste it into your tracker.
Schedule a follow-up two business days before the posted decision window closes.
Marketplace vs. Medicaid: Subtle Differences That Matter
Marketplace (Ambetter): Expect strict alignment with the product formulary and commercial step-therapy logic. Some categories (e.g., oncology) may use condition-specific vendor pathways; follow the product’s portal directions.
Medicaid (AHCCCS): Coverage criteria and preferred drug lists can differ from Marketplace. Requirements for certain baseline tests, quantity limits, and exception rationales may vary; submit in the Medicaid-specific portal flow and use the language that mirrors Medicaid criteria.
No matter the product, the one-page summary + precise evidence approach is the fastest path to “approved.”
Real-World Scripts You Can Reuse
Patient → Clinic (At the Counter):
“Hi, this is [Full Name, DOB]. The pharmacy says [Drug, Dose] for my Arizona Complete Health plan needs prior authorization. My member ID is [ID], the pharmacy is [Name/Phone]. Could you please submit the PA today? I can share prior meds and any labs you need.”
Clinic → Plan/PBM (Status Check):
“Calling about PA for [Patient, DOB, ID, Drug]. Submitted via ePA on [Date], confirmation [ID]. Do you have all required information? What’s the current status and target decision date? We can upload any requested labs or notes today.”
Clinic → Specialty Pharmacy (After Approval):
“Authorization obtained for [Drug, Dose, Days’ Supply] for [Patient] under Arizona Complete Health. Please process and contact the patient at [Phone]. Monitoring includes [brief items]; injection teach is scheduled [Date].”
Follow-Up Rhythm That Protects Your Timeline
Day 0 (Submission): Save confirmation ID; verify patient contact; note the required specialty pharmacy.
Day 1–2: If pending, respond same day with exactly the requested item(s); add a two-line note listing the attachments.
Two Business Days Before the Decision Window Ends: Status check via portal/phone; request the decision date and add notes to your tracker.
If Denied: If the issue is clinical nuance, schedule a peer-to-peer review; otherwise file a tight appeal that quotes criteria and answers it point-by-point with only the necessary evidence.
Common Pitfalls And Fast Fixes
Dose/Quantity Mismatch between eRx and form → Reconcile and resubmit with a one-line note acknowledging the correction.
Vague Step-Therapy Notes (“tried others”) → Add drug names, dates, adherence, outcomes, and adverse events.
Missing Safety Labs the criteria require → Upload the reports (with dates/values) and reference them in your one-pager.
Wrong Pharmacy Channel → If the plan mandates a specialty pharmacy, re-route the eRx immediately after approval and tell the patient who will call.
Unreachable Patient → Confirm phone/email and advise the patient to expect calls/texts from the plan or specialty pharmacy within the decision window.
Specialty Logistics: Get Ahead of Delays
Specialty drugs often require teaching, cold-chain shipping, and/or financial assistance. Start these in parallel with the PA:
Enroll the patient in manufacturer assistance (copay/bridge) at submission.
Schedule teach visits (injection training) for the week of the expected approval.
Verify delivery windows and address; confirm caregiver availability.
Set refill reminders around day 21–23 of a 28-day cycle to catch issues early.
Build a Mini “PA Pod” for Reliability
Even a small practice can run a high-throughput specialty PA engine with a three-person pod:
Intake & Routing Lead: Confirms plan/product, specialty-pharmacy rules; launches ePA; logs the confirmation ID.
Clinical Packager: Writes the one-page summary; compiles labs/notes; checks for dose/quantity consistency.
Tracker & Escalations: Watches timelines; responds to pends same day; schedules peer-to-peers/appeals when necessary.
Hold a 15-minute weekly huddle to review “Pending > 3 Business Days” and fix the top three causes as a team.
FAQs
Do I always need the NDC?
Not always, but some flows require it. If the form asks, list the NDC that matches your eRx to avoid a mismatch pend.
Can the plan force a specific specialty pharmacy?
Yes for many specialty therapies. If one is required, route your eRx there immediately after approval.
How long does a decision take?
Varies by product, therapy class, and completeness. A complete ePA packet commonly moves in a few business days. Track the posted window and follow up before it closes.
If the member changes insurance mid-therapy?
You’ll likely need to repeat PA with the new plan. Ask about transition-of-care options to prevent gaps.
Do approvals expire?
Yes—many approvals expire after 6–12 months or a set number of fills. Set a re-auth reminder.
Arizona-Ready One-Page Templates
One-Page Specialty Medication Summary (Pharmacy PA)
Patient / Plan: [Name, DOB, Member ID, Medicaid/Ambetter]
Drug & Regimen: [Name, strength, route, quantity per fill, days’ supply, titration]
Diagnosis: [ICD-10] + key severity/functional notes
Treatment History: [Drug, dates, adherence, outcomes, AE, reason for stop] × 2–3
Safety & Monitoring: [TB/LFTs/eGFR/etc. with dates/values; monitoring cadence; stop rules]
Rationale: [Why this drug now; risk of delay]
Routing: [Portal/ePA confirmation ID; required specialty pharmacy; teach visit date]
Step-Therapy Block
[Drug] [dose] — [mm/dd/yyyy–mm/dd/yyyy], adherence ~[x%]; outcome [metric]; AE [if any]; stopped because [reason].
[Drug] [dose] — [mm/dd/yyyy–mm/dd/yyyy], adherence ~[x%]; outcome [metric]; AE [if any]; stopped because [reason].
Safety-Labs Block
TB-Quantiferon: [date] result [neg/pos + value]
AST/ALT: [date] [values]; SCr/eGFR: [date] [value]
Pregnancy test: [date] [result] (if applicable)
Monitoring: [metric] every [interval]; stop if [criteria]
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