Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage

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Prior Authorization Form
Medicare Administrative Prior authorization for Part B/D coverage
ONLY COMPLETED REQUESTS WILL BE REVIEWED
Date: __________________________
Patient ID#: ________________ DOB:___________
Patient Name: _______________________________
Provider NPI: _______________________________
Prescribing Physician: _________________________
Office Contact: ______________________________
Office Fax #: _______________________________
Office Phone: _______________________________
HEPATITIS B VACCINE
High or Intermediate Risk, diagnosis code: _________________________________________
Other (please provide diagnosis and code): _________________________________________
PARENTERAL NUTRITION (TPN)
(Drug requested): _____________________________________________________________
Does the patient have a permanent dysfunction of the digestive tract?
Yes
No
INTRADIALYTIC PARENTERAL NUTRITION (IDPN)
(Drug requested): ___________________________________________________
Diagnosis and diagnosis code: ________________
INTRAPERITONEAL NUTRITION (IPN)
(Drug requested): ________________________________________________________
Diagnosis and diagnosis code: ____________________
ALL OTHER INTRAVENOUS (IV) MEDICATIONS
(Drug requested): ________________________________________________
home setting via an external infusion pump
Is the requested drug administered in the
?
Yes
No
ORAL CHEMOTHERAPY AGENTS
(Drug requested): ____________________________________________________________
Diagnosis and diagnosis code: ________________________________________________________________________
INTRAVENOUS IMMUNE GLOBULIN (IVIG)
For re-authorization requests:
Primary Immunodeficiency, diagnosis code:
(documentation of clinical improvement using objective monitoring as
____________________________________________
appropriate to the diagnosis such as, but not limited to, Rankin score and
Activities of Daily Living (ADL) scores must be provided)
Other, diagnosis and diagnosis code:
_________________________________________________
____________________________________________
_________________________________________________
____________________________________________
_________________________________________________
_________________________________________________
NEBULIZED SOLUTIONS
(Please circle drug): acetylcysteine (Mucomyst®), albuterol (Accuneb®, Airet®,Proventil®,Ventolin®, ), cromolyn (Intal®),
albuterol and ipratropium (DuoNeb™), ipratropium metaproterenol (Alupent®), budesonide(Pulmicort Respules®), dornase
alfa (Pulmozyme®), tobramycin ( TOBI®), levalbuterol (Xopenex®), iloprost (Ventavis®), pentamidine isethionate
(Nebupent®), ribavirin( Virazole®), Sodium Chloride ( Hyper-Sal®; Nebusal®), treprostinil (Tyvaso®), Other:
___________________________
For use in a nebulizer
Other, diagnosis and code: _____________________________
Is the patient in a long-term care facility?
Yes
No
07/2015 PA019-Medicare B vs. D
Provider Communication

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