Form V. C-1.0 - Minnesota Uniform Form For Prescription Drug Prior Authorization (Pa) Requests And Formulary Exceptions - 2010 Page 2

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Minnesota Uniform Form for Prescription Drug Prior

Authorization (PA) Requests and Formulary Exceptions

Please do not send this form to a patient’s employer or to the Minnesota Department of Health (MDH)

or to the Minnesota Administrative Uniformity Committee (AUC).

see additional instructions and overview, Instructions page.

Please check the appropriate box below (check only one box). This form is being used for:

Formulary Exception

Prior Authorization (PA) Request

Unsure/Unknown

Destination this form is being submitted to:

(Payers making this form available on their websites may pre-populate section A.)

HealthPartners

Payer Name: _______________________________________________________________________________________________________________________

Pharmacy Administration

Payer Contact Name: __________________________________________________________________________________________________________________

(iF AvAiLAbLe)

Minneapolis, MN 55440-1309

P.O. Box 1309, Mail Route 22205A

Payer Address: _________________________________________________________________ City, State, ZIP: __________________________________________

952-883-5813

952-853-8700

Toll Free Fax: 1-888-883-5434

Payer Phone: ______________________________ Secure Fax: ___________________________ Other: ________________________________________________

Patient Information

When filling Patient Health Plan ID number below, please note: If the patient has prescription benefits that are separate or “carved out” from the health plan benefits, provide

the patient’s prescription benefit card ID number (the “cardholder ID”). If the patient’s prescription benefits are integrated with the health plan coverage (if there is no

separate prescription benefit ID number), provide the patient’s health plan ID number.

Patient Name: _________________________________________________________________ DOB: _________________________________________________

(LAst, First, Mi)

(MM / DD / yyyy)

Patient Address: _______________________________________________________________ City, State, ZIP: __________________________________________

Gender. Please Check Box:

Male 

Female 

Unknown

Health Plan or Prescription Plan: ___________________________________________________ Patient Health Plan ID No.: _________________________________

(or PrescriPtion PLAn id iF diFFerent thAn heALth PLAn id)

Prescriber Information

Prescriber Name: _______________________________________________________ NPI: ___________________ Specialty: ________________________________

(LAst, First, Mi)

Prescriber Business Address: ______________________________________________ City, State, Zip: ____________________________________________________

Prescriber Phone: _______________________________________________________ Prescriber Secure Fax: ______________________________________________

Prescriber Point of Contact (POC) Name: _____________________________________ POC Phone: ____________________ POC Secure Fax: _____________________

(iF diFFerent thAn Prescriber)

Clinic/location/Facility Name: ____________________________________________ Clinic/location/Facility Contact Name: __________________________________

Clinic/location/Facility Phone: ____________________________________________ Secure Clinic/location/Facility Fax: _____________________________________

Clinic/location/Facility Address: ___________________________________________ City, State, ZIP: __________________________________________________

Prescription Drug Information (Medication information)

When completing this section and the following section (E), medication “strength” is usually expressed in milligrams, e.g., 30 mg, 15 mg/ml, etc. Medication “dosing

schedule” is used to report how often the patient will take/use the medication, e.g., daily, four times per day, every four hours, as needed, etc.

Drug Being Requested: _________________________________________________ Strength: _______________________________________________________

(requested drug nAMe)

(e.g., 30 Mg, 15 Mg/ML, etc)

Dosing Schedule: ______________________________________________________ Date Therapy Initiated: ______________________________________________

Duration of Therapy Expected: ____________________________________________ Authorization Start Date: ___________________________________________

Clinical Drug Trial Request?

yes

Is Dispense as Written (DAW) Specified?

yes

(note: the MinnesotA dePt. oF huMAn services does not cover cLinicAL drug triALs.)

Rationale for DAW? ___________________________________________________________________________________________________________________