Fillable Unitedhealthcare Prior Authorization Request Form

Unitedhealthcare Prior Authorization Request Form - Fenofibrate

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24 HOUR – URGENT

FENOFIBRATE

PRIOR AUTHORIZATION REQUEST

Complete ENTIRE form and Fax to: 866-940-7328

Today‘s Date:

SECTION A - PATIENT INFORMATION

First Name:

Last Name:

Member ID:

Address:

City:

State:

Zip:

Phone:

DOB:

Allergies:

Primary Insurance:

Policy #:

Group #:

□

Is the requested medication NEW

or a CONTINUATION of THERAPY

? If so, start date:__________

□

Is this patient currently hospitalized?

Yes

SECTION B - PHYSICIAN INFORMATION

First Name:

Last Name

M.D./D.O

Address:

City:

State:

Zip:

Phone:

Fax:

NPI #:

Specialty:

Office Contact Name / Fax Attention to:

SECTION C - MEDICAL INFORMATION

Medication:

Strength:

Directions for use:

Diagnosis (Please be specific & provide as much information as possible):

ICD-10 CODE:

Has the patient attempted therapy with 30 day trial of a statin (e.g. simvastatin, pravastatin, lovastatin, Lipitor,

Crestor, Vytorin) or a 90 day trial of gemfibrozil? Yes____ No____

If Yes, list dates of therapy: ________________________________________________________________________

Is fenofibrate being prescribed for use in combination with a statin (e.g. simvastatin, pravastatin, lovastatin,

Lipitor, Crestor, Vytorin)? Yes____ No____

If yes, list statin: _________________________________________________________________________________

Has treatment with gemfibrozil for at least 90 days failed to adequately treat the patient’s condition?

Yes____ No____ List date and result of current triglyceride level:___________________ (normal is <150mg/dL)

Has the patient experienced an intolerance/adverse reaction or a contraindication to previous therapy with

gemfibrozil? Yes____ No____ If yes please provide intolerance/adverse reaction details: ____________________

________________________________________________________________________________________________

If requesting a non-preferred fenofibrate (i.e. Antara, Lipofen, Fenoglide, Tricor, Triglide, Trilipix, Fibricor):

Has the patient tried and failed therapy with gemfibrozil and generic fenofibrate (fenofibrate or fenofibrate

micronized)? Yes____ No____

List dates of therapy, medications, and doses: _________________________

Physician Signature

Date:

: ________________________

_______________

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the use of UnitedHealthcare. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action involving the contents

of this document is prohibited. If you have received this telecopy in error, please notify the sender immediately.

Phone: 800-310-6826

Fax: 866-940-7328

Website: