Specialty Pharmacy Prior Authorization Form

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SPECIALTY PHARMACY PRIOR AUTHORIZATION FORM
MAGNOLIA HEALTH PLAN, MISSISSIPPI
FAX this completed form to 1-855-678-6976
OR Mail requests to: US Script PA Dept., 2425 West Shaw Avenue, Fresno, CA 93711
:
Patient
Office
Other: ________________
Specialty Pharmacy Provider Ship to
Name of Specialty Pharmacy Provider: ________________________________________________________________
MEMBER INFORMATION
PROVIDER INFORMATION
Patient Name: _____________________________
Prescriber Name: ____________________________
Address: _________________________________
NPI#: ______________________________________
City, State Zip: _____________________________
Group or Hospital: ____________________________
Home Phone: _____________________________
Address: ___________________________________
Alternate Phone: ___________________________
City, State Zip: ______________________________
Date of Birth: ______________________________
Phone: ____________________________________
Gender: __________________________________
Fax: _______________________________________
Contact Name: ______________________________
INSURANCE INFORMATION
Primary Insurance: _________________________ ID#: _____________________ Phone#: ______________
Secondary Insurance: _______________________ ID#: _____________________ Phone#: ______________
DIAGNOSIS
ADDITIONAL CLINICAL INFORMATION
Please include ICD9 and description
Weight: _____________ kg/lbs
_______________________________
Height:______________ in/cm
_______________________________
Lab Data (Please include copies of reports):__________________
_______________________________
_____________________________________________________
_______________________________
Other Medications: _____________________________________
_______________________________
_____________________________________________________
Date of Diagnosis: ________________
Additional Comments: ___________________________________
(Please include any diagnostic clinicals
_____________________________________________________
such as labs, radiology, exams, etc.)
Is member currently treated with this medication(s)? No ___ Yes ___How long: __________________________
Is this request a continuation of a previous approval by Magnolia Health Plan? No ___Yes ___
Has the strength, dosage or quantity required per day: Increased ________ Decreased ________ Same ______
MEDICATION(S) REQUESTED
Therapy Start Date: _________________
Medication Name
Strength/Dose
Directions
Quantity
Refills
_____________________________________________________
_______________________
Prescriber’s Signature
Date
US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior
authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing.

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