Consumers Choice Health Plan printable pdf download

Consumers Choice Health Plan

PHARMACY PRIOR AUTHORIZATION APPEAL FORM

Phone: 855-577-6547

Fax: 866-511-2202

US mail: Catamaran

Prior Authorization and Appeals

PO Box 5252

Lisle, IL 60532

Prescriber Information

Name:

Specialty:

DEA/NPI:

_Phone:

Fax:

Pharmacy Information

Name_________________________ Phone____________ Fax:

____

Patient Information

Name:

Date of Birth:

Member ID:

Medication Information:

Name and Strength of Drug:

Quantity & Dosing:

Diagnosis:

Duration of Therapy: _

Prior Authorization Appeal Form

1. Is the medication requested medically necessary for the patient?(Document reasoning below):

Please attach the following documentation to support your appeal:



A copy of the denial letter received from the Catamaran Prior Authorization Department



Physician letter in support of the appeal, or other supporting documentation

Other Diagnosis/Comments:

Information given on this form is accurate as of this date.

Prescriber or Authorized Signature

Date

___________________________________

_______________

Consumers’ Choice Health Plan I P.O. Box 91606 I Lubbock I Texas I 79490-1606 I

Consumers Choice Health Plan