Prior Authorization Request Form For Prescription Drugs

Prior Authorization Request Form For Prescription Drugs - Us Script

Prior Authorization

Request Form for

Prescription Drugs

FAX this completed form to 866-399-0929

OR Mail requests to: US Script PA Dept / 2425 West Shaw Avenue / Fresno, CA 93711

I. Provider Information

II. Member Information

Prescriber name (print):

Member name:

Office contact name:

Identification number:

Group name:

Group number:

Fax:

Date of Birth:

Phone:

Medication allergies:

III. Drug Information (One drug request per form)

Drug name and strength:

Dosage form:

Dosage Interval (sig):

Qty per Day:

Diagnosis relevant to this request:

Expected length of therapy:

Medication History for this Diagnosis

Is member currently treated on this medication?

yes; How Long?_______________

no [skip items B & C; go to item D]

[go to item B]

Is this request for continuation of a previous approval?

yes [go to item C]

no [skip item C; go to item D]

Has strength, dosage, or quantity required per day increased or decreased?

yes [go to item D]

no [skip item D; indicate rationale for continuation in Section IV and submit form]

Please indicate previous treatment and outcomes below.

Drug Name

Dates of Therapy

Reason for Discontinuation

(include strength and dosage)

NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Health Republic

(Select your state, then click "What We Offer", select your section, then to "Medication Coverage".)

Formulary is available at

IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)

Appropriate clinical information to support the request on

Provider Signature:

Date:

the basis of medical necessity must be submitted.

US Script will respond via fax or phone within 72 hours of receipt of all necessary information, except during weekends or holidays.

Requests for prior authorization (PA) requests must include member name, ID#, and drug name. Incomplete forms will delay processing.

Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.)

Prior Authorization Request Form For Prescription Drugs - Us Script

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