Medication Prior Authorization Request Form

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Medication Prior Authorization Request Form
Your request cannot be processed without complete information which includes
provider specialty.
Member Information
Member name:
Member ID:
Date of birth:
Sex:
**Expedited/Urgent
**By checking this box, I certify applying the standard review
Female
Male
time frame may jeopardize the health of the member or the
member’s ability to regain maximum function.
Provider Information
Provider name:
Provider NPI#:
Phone:
Fax:
Specialty:
Name & title of person completing form:
Medication Information
Drug name
Strength
Administration schedule
Length of therapy
Quantity required
Patient diagnosis for use of medication
Previous history of a medical condition, allergies or other pertinent medical information that necessitates use of this medication:
Has the patient been seen by any other provider for this condition?
Yes
No
If so, what what the prescriber’s specialty:
Previous non-prior authorized and prior authorized medications tried and failed for this condition:
Name of medication
Reason for failure
Date
Pertinent laboratory test or procedure (if applicable)
Procedure
Findings
Date
Other Information:
To Prescriber- Complete ENTIRE form and send to:
Magellan Rx Prior Authorization Department
2520 Industrial Row Dr, Troy, MI 48084
Phone: 1-248-540-6686
Fax: 1-888-656-3604
The fax number is only for prior authorization requests.
Pharmacy will only accept original prescription orders from patients.
Faxed prescriptions can be accepted if faxed to the member’s pharmacy by the prescribing physician.
4D_MRX1056_1116

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