Pharmacy Management Request For Prior Authorization Form
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1Request for Prior Authorization Form
Submit requests to:
4D Pharmacy Management
2520 Industrial Row Drive
Troy, MI 48084
Phone: 248-540-6686 Fax: 248-341-8133
***Please submit one drug per PA form***
Prescribing Physician:
Beneficiary:
Name: _________________________________________
Name: _____________________________________________
First
Last
First
Last
Direct Phone: __________________________________
Member ID#________________________________________
Fax: ____________________________________________ Date of Birth: _______________________________________
Physician Specialty: _____________________________ Sex:
Female
Male
NPI number: ____________________________________ Phone: ____________________________________________
Name & title of person completing form: _______________________________________________________________
Drug Name
Strength
Administration Schedule
Length of Therapy
Quantity Required
Patient’s diagnosis for use of this medication: __________________________________________________________
1. Previous history of a medical condition, allergies or other pertinent medical information, that
necessitates the use of this medication: ____________________________________________________________
2. Has the patient been seen by any other provider for this condition?
Yes
No
a. If so, what was the prescriber’s specialty____________________________________________________
3. Previous non-prior authorized and prior authorized medications tried and failed for this condition:
Name of medication
Reason for failure
Date
4. Pertinent laboratory test or procedure: (if applicable)
Procedure
Findings
Date
5. Other Information:
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Parent category: Medical