Arizona Health Care Cost Containment System (Ahcccs)
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1Arizona Health Care Cost Containment System (AHCCCS)
Medication Request Form
DO NOT WRITE IN BLOCKED AREAS
DO NOT WRITE IN BLOCKED AREAS
FOR INTERNAL USE ONLY
FOR INTERNAL USE ONLY
Contacted:
Approved:
Effective 10/01/2015
Prescriber:
Optum Rx Prior Authorization Department
Denied:
Pharmacy:
P.O. Box 5252
Returned:
Patient:
PA #
Lisle, IL 60532- 5252
Instructions:
This Medication Request Form is only for use by prescribing clinicians for AHCCCS FFS members and must be signed by the prescribing
clinician. In addition to member identifying data, the prescribing clinician must provide the medication requested, the dosage and the
clinical justification/rationale for the request. If the request is for a drug not listed on the AHCCCS Drug List, the documentation must
demonstrate why the member cannot use the medication(s) listed on the drug list. The Medication Request Form is also used to request
overrides for step therapy, quantity limits and other edits. If you have any questions regarding this process, please contact Optum Rx’s
Customer Service at (855) 577-6310. Please complete this form and fax to Optum Rx at (866) 463-4838.
Retail & Long Term Care Pharmacy Instructions for After Hours Emergencies, Hospital Discharges & Care Transitions
The participating network pharmacy staffs are to contact the Optum Rx’s Customer Service Unit at (855) 577-6310 to request medication
overrides for after-hours emergencies, hospital discharges or patients transitioning from the hospital to a lower level of care; this also
includes antibiotics infusion requests.
CHECK HERE IF THE PATIENT IS A DIRECT TRANSFER FROM A HOSPITAL TO A LONG TERM CARE FACILITY.
CHECK HERE TO REQUEST AN EXPEDITED (URGENT) REVIEW: BY CHECKING THIS BOX, I CERTIFY THAT APPLYING THE STANDARD REVIEW TIME FRAME
MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION.
Medication Request Information (please complete each section of this form prior to submission): *Denotes Required Fields
PATIENT INFORMATION
PRESCRIBING CLINICIAN INFORMATION
*Name:
*Name:
*ID#:
*Specialty:
*Date of Birth:
ID# / DEA#:
*Health Plan:
*Phone: (
)
-
*Fax: (
)
-
*Diagnosis (ICD-10 Code, if known):
REQUESTED DRUG INFORMATION
PHARMACY INFORMATION
*Requested Drug:
Name:
*Dose:
*Strength:
Phone: (
)
-
Fax: (
)
-
*Quantity:
Dosage Form:
*Length of Treatment:
(per month)
(Oral, Injection, etc.)
(Please be specific.)
*Clinical Justification for the Requested Medication:
*Other Medications Tried and/or Failed (Please be specific, give detail.):
Additional Information / Other Pertinent History:
*Prescriber Signature Required:
*Date:
Revised: 09/29/2015
Effective: 10/01/2015
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