Drug Prior Authorization Form

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Drug Prior Authorization Form
Medicaid Phone: (888) 898-7969
Michigan Marketplace Phone: (855) 322-4077
Wisconsin Marketplace Phone: (855) 326-5059
Fax: (888) 373-3059
Please make copies for future use.
Date of Request:
Patient DOB:
Patient Name (Last):
(First):
Patient ID (10 digit):
Name of Person Completing form:
Provider’s Name and Specialty:
Provider’s Address:
Phone #: (Area Code)
(Number)
Fax #: (Area Code)
(Number)
□
□
□
Hospital Discharge
New Request
Reauthorization
□
/
Caremark Specialty Injectables
Non-Formulary Medications: Progress notes
□
Cholesterol lowering (ie. Crestor, Vytorin, Zetia, Lovaza): Lipid Panel drawn within the last 90 days
□
Diabetes (ie. Actos, Januvia): A1c Report drawn within the last 90 days
□
Proton Pump Inhibitor (BID dosing only): Endoscopy Report
□
Pain Management: Medication Log, Progress Notes
Drug Requested: One drug request per form
Name
Strength
Dose
Quantity
**OR**
Name of Treatment
Number of
J Code
ICD
Tax ID of Treatment Facility
Facility
Units
 Estimated length of need:
 Diagnosis:
 Previous medications prescribed and outcome:
Prior Authorization form and Formulary booklet may be found at
Revised 10_15_ddg

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