Prior Authorization Request Form - Health Partners Plans (Page 2 of 2) in pdf

Prior Authorization Request Form - Health Partners Plans Page 2

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:

functional impairment (ie. increased amount of hospitalizations, safety risk)? Please submit documentation.



Yes



Q9. Requested duration:



12 months

Other:_________

Q10. Additional comments:

___________________________________________________________

_________________________________________

Prescriber Signature

Date

Updated 2015

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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