Medication Prior Authorization Request Form

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Louisiana Healthcare Connections
MEDICATION PRIOR AUTHORIZATION REQUEST FORM
→
☐
A. Is the request for a
Complete section
and FAX to the number provided
SPECIALTY
MEDICATION:
YES
B
→
☐
FAX to 1-866-399-0929
NO
→
☐
B. If SPECIALTY, choose ONE of the following:
Dispense from
FAX to 1-877-401-8172
OFFICE STOCK
→
☐
FAX to 1-866-399-0929
SPECIALTY PHARMACY
If specialty pharmacy, complete the following:
☐
☐
Ship to (choose one):
Member’s Home
Prescriber’s Office
______________________________________
Pharmacy Name:
_____________________________________
Pharmacy Address:
________________________________
TODAY’S DATE: ___________________
Pharmacy Phone Number:
I. MEMBER INFORMATION
II. PRESCRIBER INFORMATION
Name:
Name:
ID Number:
Specialty:
Gender:
NPI or DEA Number:
Date of Birth:
Group or Hospital:
Address:
Address:
City, State, Zip:
City, State, Zip:
Primary Phone:
Phone:
Alternate Phone:
Fax:
Medication Allergies:
Office Contact Name:
III. INSURANCE INFORMATION
(FOR SPECIALTY MEDICATION REQUESTS ONLY)
Primary Insurance:
ID Number:
Phone Number:
Secondary Insurance:
ID Number:
Phone Number:
IV. MEDICATION REQUESTED (one medication request per form)
Drug Name:
Dosage/Strength:
Dosage Form:
Route of Admin:
Quantity Per Day:
Directions:
Refills/Length of Tx:
Therapy Start Date:
V. DIAGNOSIS (as relevant to this request)
Diagnosis:
ICD9:
Date of Diagnosis:
NOTE: Include diagnostic clinicals (e.g. labs, radiology, etc.).
VI. ADDITIONAL CLINICAL INFORMATION
(FOR SPECIALTY MEDICATION REQUESTS ONLY)
Height (in/cm):
Weight: (kg/lb):
Lab Data (include copies):
Other Medications:
Additional Comments:
VII. MEDICATION HISTORY (for this diagnosis)
A. Is the member currently on this medication? ☐Yes; if yes, how long? ______ ☐No; if no, skip to items B&C, go to D.
B. Is this a request for continuation of a previous approval? ☐Yes; if yes, go to item C. ☐No; if no, skip item C, go to D.
C. Has the strength, dosage, or quantity required per day: ☐Increased ☐Decreased ☐Remained the Same
D. Indicate previous treatment/outcomes with other medications below.
NOTE: Confirmation will be made using claims history.
Drug Name, Strength, and Dosage
Dates of Therapy
Reason for Discontinuation
1
2
3
VIII. RATIONALE FOR REQUEST and PERTINENT CLINICAL INFORMATION
NOTE: Appropriate clinical information to support this request is required for all PA’s. Attach additional sheets if more space is needed.
Prescriber Signature – Substitution Permitted:
Prescriber Signature – Dispense as Written (DAW):
__________________________________ Date: __________
__________________________________ Date: __________
Please access
or contact provider services for a current listing of preferred products. A response will be provided via fax or phone within
24 hours of receipt of the request. Incomplete and illegible forms will delay processing. Be sure to include lab reports with requests when appropriate.
To request a 72 hour
Requests can also be
emergency supply of medication you may call US Script at 1-888-929-3790.
NOTE: The 72 hour supply does not apply to specialty medications.
mailed to: US Script PA Department., 2425 W. Shaw Ave., Fresno, CA 93711.

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