General Specialty Medication Pa Form - Prior Authorization Form/ Prescription

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Primary Diagnosis
General Specialty Medication PA Form
Prior Authorization Form/ Prescription
Date: ___________ Date Medication Required:____________
Phone: (855) 304-5580 Fax: (855) 815-9894
Ship to:
Physician
Patient’s Home
Other __________
Patient Information
Last Name:
First Name:
Middle:
DOB: ____/____/_____
Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Sex:
Male
Female
Insurance Information (Attach Copies of cards)
Primary Insurance:
Secondary Insurance:
ID #
Group #
ID #
Group #
City:
State:
City:
State:
Physician Information
Name:
Specialty:
NPI:
Address:
City:
State:
Zip:
Phone # (
)
Secure Fax #: (
)
Office contact:
Prescription Information
MEDICATION
STRENGTH
DIRECTIONS
QUANTITY
REFILLS
Primary Diagnosis
Primary ICD-9/ICD-10 Code: ___________________________
Description in words: _____________________________________________________________________________________
Clinical Information
***** Please submit supporting clinical documentation*****
INITIAL THERAPY
CONTINUATION OF THERAPY;
Therapy start date: _____________________
Patient’s weight _______________________ kg
Patient’s height ________________________ inches
1.
Is the member currently treated with this medication?
Yes
No
2.
If continuation of therapy, how long has the patient been on treatment? __________
years
months
3.
Has the patient had a positive outcome?
Yes
No
4.
Please indicate previous treatment and outcomes?
Note: This form is to be used to request review for Specialty Medication where there is no drug specific form. For non-specialty medication,
please use US Script Prior 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)
DAW
Physician’s Signature
Date: ________________________
________________________________________________

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