Prior Authorization Request Form - Health Partners Plans

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HEALTH PARTNERS PLANS
PRIOR AUTHORIZATION REQUEST FORM
Abilify Maintena
Phone: 215-991-4300
Fax back to: 866-240-3712
Health Partners Plans manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician.
Please answer the following questions and fax this form to the number listed above.
PLEASE NOTE: Any information (patient, prescriber, drug, labs) left blank, illegible, or not attached WILL delay the review process.
Patient Name:
Prescriber Name:
Member Number:
Fax:
Phone:
Date of Birth:
Office Contact:
Address:
NPI:
State Lic ID:
City, State ZIP:
Address:
Primary Phone:
City, State ZIP:
Line of Business: □ Medicaid
□ CHIP
Specialty/facility name (if applicable):
□ Expedited/Urgent
Drug Name:
Strength:
Directions / SIG:
1
Please attach any pertinent medical history including labs and information for this member that may support approval.
Please answer the following questions and sign.
Q1. Has the patient tried and failed Risperdal® Consta® and Invega® Sustenna?
Yes
No
Q2. Is the member over the age of 18?
Yes
No
Q3. Does the member have a diagnosis of schizophrenia?
Yes
No
Q4. Has the patient been started on Abilify MaintenaTM while inpatient? Please provide discharge summary with date of
last injection.
Yes
No
Q5. Has the member tolerated treatment with oral Abilify® (aripiprazole) at a dose of 10 to 20 mg per day?
Yes
No
Q6. Does the patient have a history of long-term (greater than 3 months) non-compliance with oral antipsychotic
medication which would prevent the patient from using oral formulary atypical antipsychotic medication? Please submit
documentation.
Yes
No
Q7. Has the member failed measures (such as psychosocial interventions, psychoeducational interventions that have a
behavorial component and supportive services, and providing member with instructions and problem-solving strategies
such as reminders, self-monitoring tools, cues, and reinforcements) to improve compliance with formulary oral
medications? Please submit documentation.
Yes
No
Q8. Does the member have significant clinical decompensation, or is the member at high risk for decompensation and
This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or
entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are
hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in
error, please notify the sender immediately to arrange for the return of this document
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