Specialty Medication Prior Authorization Form

SPECIALTY MEDICATION

PRIOR AUTHORIZATION FORM

Complete this form and send information to

Peach State Health Plan, Pharmacy Department

fax at 1-866-374-1579

For questions, please call 800-514-0083 option 2

Ship

Caremark Ship to:

Patient

Other OR

Dispense from Office, Hospital, or Outpatient Center Stock

PATIENT INFORMATION

PRESCRIBER INFORMATION

Patient Name: ______________________________

Prescriber Name: _____________________________

Address: __________________________________

Specialty: __________________________________

City, St Zip: _______________________________

NPI#: ______________________________________

Home Phone: ______________________________

Group or Hospital: ____________________________

Alternate Phone: ____________________________

Address: ____________________________________

Date of Birth: ______________________________

City, St Zip: _________________________________

Gender: ___________________________________

Phone: _____________________________________

OTHER SHIPPING LOCATION INFORMATION

Fax: _______________________________________

Name: _____________________________

Contact Name: _______________________________

Address: __________________________________

Name of Location Medication to be Supplied from

City, St Zip: _______________________________

if not shipped by Caremark: _________________

Phone: ___________________________________

Phone: _____________________________________

Fax: _____________________________________

Fax: _______________________________________

Contact Name: ____________________________

Contact Name: _______________________________

INSURANCE INFORMATION

Primary Insurance: ____________________________ ID#: ________________________ Phone#: ______________

Secondary Insurance: __________________________ ID#: ________________________ Phone#: _______________

STATEMENT OF MEDICAL NECESSITY

Diagnosis (please include ICD9 and description):

_______________________________________________________________________________________________________

Date of Diagnosis: __________ Please include any diagnostic clinicals such as labs, radiology, exams, etc to support diagnosis

For Chemotherapy Medication Requests, please include Chemotherapy Regimen and Anticipated Dates of Service Requested

Is member currently treated with this medication(s)? No ____ Yes _____ How long: _______________________

Is this request a continuation of a previous approval by Peach State? No ____ Yes ____

Has the strength, dosage or quantity required per day: Increased _______ Decreased __________ Same _______

MEDICATION(S) REQUESTED

Medication Name

Strength/Dose Directions

QTY Refills

Therapy

Start

Date

_____________________________________________________

_______________________

Prescriber’s Signature

Date

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