Prior Authorization Form

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1650 Spring Gate Lane
Las Vegas, NV 89134
Tel: 888-869-4600
Please Note: Medical Necessity Prior Authorization may be utilized to override both formulary coverage and benefit design
restrictions. They are issued at the full discretion of the benefit manager.
PRIOR AUTHORIZATION FORM
COMPLETE AND FAX TO CATAMARAN™ AT 888-852-1832
MEMBER INFORMATION
First Name
Last Name
Plan
Member ID
Date of Birth
DRUG INFORMATION
Drug Name
Quantity
ICD-9
Directions
Duration of Therapy
Diagnosis
PLEASE LIST ALTERNATIVE THERAPIES THAT HAVE BEEN ATTEMPTED AND ANY OTHER PERTINENT INFORMATION RELATED
TO DRUG AND/OR DISEASE STATE. IF NOT PRESENT, WITHIN NORMAL LIMITS WILL BE USED FOR THE REVIEW.
Medication/Failure Reason:
IgE:______________
ESR:_______________
CRP:_______________
# Joints:_______________
%BSA:______________
Height:_______________
Weight:_______________
BMI:_______________
HA1C:_______________
Hemoglobin:_______________
Hematocrit:_______________
T-Score:_____________
Dialysis:_____________
Long Term Care Facility:_____________
Self Injecting:_____________
Stimulation test:__________/__________
Growth velocity:___________
#Chemotherapy cycles/month:__________
Mini-Mental Status Test:____________
Baseline Free testosterone/Total testosterone:__________/_________
HCV RNA viral load:______________
Viral Genotype:_______________
ALT:_______________
PHYSICIAN INFORMATION
Physician Signature
Date
Physician Name
NPI #
Phone Number
Fax Number
Only mark Urgent when standard review time
would seriously harm the member’s life or
Action Needed
Pharmacy Fax
health or ability to regain maximum function
Urgent
For Review
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