Us Script Prior Authorization Request Form For Specialty Prescription Drugs

Prior Authorization Request

Form for Specialty

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

Patient Name: ___________________________________________________

Physician Name: _______________________________________________

Address: _______________________________________________________

State Lic #______________________ DEA # ________________________

City: ________________________________State: _______Zip:____________

NPI # _________________________ Specialty: _____________________

Home Phone: (___________) ___________ - _________________________

Practice Name/Hospital: _________________________________________

Work Phone: (_______) _____________ - _________________________

Address: _____________________________________________________

Cell Phone: (__________) _____________ - _________________________

City: __________________________ State: ________ Zip: ____________

Patient Soc. Sec #: _________________ Allergies:_______________________

Physician’s Ph: (__________) ____________ - ______________________

Date of Birth: ___/___/___ Sex:

Male

Female

Weight _____

Physician’s Fax: (__________) ____________ - _____________________

lbs

kg

Height: _______ BSA: ________ m²

See attached demographic sheet

Nurse/Key Office Contact: ________________________________________

INSURANCE INFORMATION (Complete or Attach Copies of cards)

Primary Insurance:__________________

Secondary Insurance:________________

Rx Card (PBM):_____________________

Cardholder First Name: ______________

City:______________State:___________

City:______________State:___________

PBM BIN: ________________________

Last Name: _______________________

Plan #: ___________________________

Plan #: ___________________________

City:______________State:___________

Employer: ________________________

Group #: _________________________

Group #: _________________________

Group #: _________________________

ID #: ____________________________

Phone: (______) ________-__________

Phone: (______) ________-__________

Phone: (______) ________-__________

Group #: _________________________

DIAGNOSIS (Required)

What is the ICD 9 / ICD 10 code? ____________________________

PATIENT EVALUATION

1.

Is the member currently treated with this medication?

Yes; if yes, please continue

No; if no, please continue to question #4

2. How long has the patient been on treated with this medication: ______________

years

months

3. Has the patient had a positive outcome?

Yes

No

4. Please indicate previous treatments and outcomes?

Note: This form is to be used to request review for Specialty Medication where there is no drug specific or disease specific form. For non-specialty medication please use

the US Script / Health Republic Non-Specialty PA Authorization form.

Drug Name (include strength and dosage)

Dates of Therapy

Reason for Discontinuation

1.

2.

3.

4.

NOTE: confirmation of use will be made from member history on file; prior use of preferred drugs is part of the exception criteria

5.

Please state Rationale for Request / Pertinent Clinical Information (Required for all prior authorizations)

**NOTE: We can NOT make a decision without a copy of pertinent lab results and/or the current clinical progress notes - Thank You**

MEDICATION

STRENGTH

DIRECTIONS

QUANTITY

REFILLS

Physician’s Signature: ____________________________________

Date____/_____/____

DAW (Dispense as Written)

IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under

applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to

disposal of the transmitted material. In no event should such material be read or retained by anyone other than the name addressee, except by express authority of sender to the name addressee.