Prior Authorization/drug Attachment Page 2
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4PRIOR AUTHORIZATION / DRUG ATTACHMENT (PA/DGA)
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F-11049 (07/2016)
SECTION IV – CLINICAL INFORMATION FOR HEALTHCHECK “OTHER SERVICES” DRUG REQUESTS
14. Document the clinical rationale to support the medical necessity of the drug being requested as a HealthCheck “Other Services”
PA request. Include documentation of previous treatments and detailed reasons why other covered drug treatments were
discontinued or not used. Medical records and peer-reviewed medical literature should be provided as necessary to support the
PA request.
Note: All HealthCheck “Other Services” drug PA requests must also include the date of the member’s most recent HealthCheck
screen, along with the name of the HealthCheck screener (who is required to be Medicaid-enrolled). HealthCheck “Other
Services” is limited to members under 21 years of age.
SECTION V – CLINICAL INFORMATION FOR DIAGNOSIS-RESTRICTED DRUG REQUESTS
15. Submit peer-reviewed medical literature to support the proven efficacy and safety of the requested use of the drug. Include
documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not used.
Medical records should be provided as necessary to support the PA request.
Continued
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