To Ensure a Timely, Response, Please Fill out the Form Completely and Legibly

PHARMACY Medication Prior Authorization

☐STANDARD REQUESTS FAX: (1) 866-399-0929 ☐EXPEDITED REQUESTS FAX: (1) 855-766-1554

To ensure a timely, response, please fill out the form completely and legibly.

Standard (Up to 14 Calendar Days)Expedited*(Up to 72 hours)
☐Physical Health Request☐Behavioral Health Request
** Definition of expedited requests: Provider indicates or the Contractor determines that following the standard timeframes for issuing an authorization decision could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function.
Member Name (Last, First):
Click here to enter text. / Member ID #:
Click here to enter text. / DOB:
Click here to enter a date. / Date:
Click here to enter a date.
Address:
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Click here to enter text. / State:
Click here to enter text. / Zip Code:
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Preferred Language:
Click here to enter text. / Gender:☐Male
☐Female / Weight:
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Legal Guardian (Name & Address):
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Requesting Provider Name:
Click here to enter text. / Practice Name:
Click here to enter text. / Specialty:
Click here to enter text. / NPI:
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Address:
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Office Contact Person:
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Please send all pertinent clinical documentation with this fax.

Use of pharmaceutical samples cannot be accepted as justification.

Diagnoses:Click here to enter text.
Name of Medication:
Click here to enter text. / Dosage:
Click here to enter text. / Quantity:
Click here to enter text. / Length of Therapy:
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Directions:Click here to enter text. / Allergies: Click here to enter text.
☐ Dispense as written / ☐Substitution Permitted / ☐Currently on this medications
List formulary medication(s)tried/contraindicated (include length of treatment and response with dates):
Click here to enter text.
Rational for the medication request:Click here to enter text.
This is a reauthorization of current medication. Recent clinical documentation is required. Please provide.
Pharmacy Name:
Click here to enter text. / Phone Number:
Click here to enter text. / Fax Number:
Click here to enter text.
Physician Signature / Date of request:
Click here to enter a date.

CONFIDENTIALITY NOTICE: This fax transmission, including any attachments, contains confidential information that may be privileged. The information is intended only for the use of the individual(s) or entity to which it is addressed. If you are not the intended recipient, any disclosure, distribution or the taking of any action in reliance upon this fax transmission is prohibited and may be unlawful. If you have received this fax in error, please notify the sender immediately via telephone at 866-495-6738and destroy the original documents. Thank you.

PMF 10.11.1

Effective 10/01/2015

Revised: 03/15-2017