Prescription Drug Prior Authorization Form
嚜燕rescription Drug Prior Authorization Form
Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation
that is important for the review (e.g., chart notes or lab data, to support the prior authorization or step-therapy exception
request [CA ONLY]). Information contained in this form is Protected Health Information under HIPAA.
NON-URGENT
EXIGENT CIRCUMSTANCES
Member Information
LAST NAME:
FIRST NAME:
PHONE NUMBER:
DATE OF BIRTH:
每
每
每
每
STREET ADDRESS:
CITY:
STATE:
MALE
FEMALE
HEIGHT (in/cm):
_________
WEIGHT (lb/kg):
_________
ZIP CODE:
ALLERGIES:
________________________________________
If you are not the patient or the prescriber, you will need to submit a PHI Disclosure Authorization form with this request which can be found at the
following link:
PATIENTS* AUTHORIZED REPRESENTATIVE (IF APPLICABLE): __________________________________________________________________
AUTHORIZED REPRESENTATIVE PHONE NUMBER:
每
每
Insurance Information
PRIMARY INSURANCE NAME:
H
A
M
A
S
PATIENT ID NUMBER:
P
I
K
SECONDARY INSURANCE NAME:
PATIENT ID NUMBER:
Prescriber Information
LAST NAME:
FIRST NAME:
PRESCRIBER SPECIALTY:
E-MAIL ADDRESS:
NPI NUMBER:
DEA NUMBER:
PHONE NUMBER:
FAX NUMBER:
每
每
每
STREET ADDRESS:
CITY:
STATE:
REQUESTOR (if different than Prescriber):
OFFICE CONTACT PERSON:
Continued on next page.
? 2017 每 2018, Magellan Health, Inc. All Rights Reserved.
Magellan Rx Management 每 Commercial Clients. Revision Date: 05/07/2018
Page 1 of 2
ZIP CODE:
每
Prescription Drug Prior Authorization Form
MEMBER*S LAST NAME:
MEMBER*S FIRST NAME:
Medication / Medical and Dispensing Information
Medication Name:
Frequency:
Dose/Strength:
Length of Therapy/#Refills:
Quantity:
New Therapy
Renewal
Step Therapy Exception Request (CA ONLY)
If Renewal: Date Therapy Initiated:
Duration of Therapy (specific dates):
How did the patient receive the medication?
Paid under Insurance Name:
Prior Auth Number (if known): _____________________
Other (explain):
Administration:
Oral/SL
Topical
Injection
IV
Other:
Administration Location:
Patient*s Home
Long Term Care
Physician*s Office
Home Care Agency
Other (explain):_________________________________
Ambulatory Infusion Center
Outpatient Hospital Care
1. Has the patient tried any other medications for this condition?
Medication/Therapy
Duration of Therapy
(Specify Drug Name and Dosage)
(Specify Dates)
YES (if yes, complete below)
NO
Response/Reason for Failure/Allergy
2. List Diagnoses:
ICD-10:
3. REQUIRED CLINICAL INFORMATION 每 Please provide all relevant clinical information to support a prior authorization or step
therapy exception request review (CA ONLY).
Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if
patient has any contraindications for the health plan/insurer preferred drug. Lab results with dates must be provided if needed
to establish diagnosis, or evaluate response. Please provide any additional clinical information or comments pertinent to this
request for coverage, including information related to exigent circumstances, or required under state and federal laws.
Attachments
Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health
Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to
verify the accuracy of the information reported on this form.
Prescriber Signature or Electronic I.D. Verification: ________________________________ Date: ____________________
Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you
are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of
these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via return FAX) and
arrange for the return or destruction of these documents.
Fax This Form to: 1-800-424-3260
Mail requests to: Magellan Rx Management Prior Authorization Program; c/o Magellan Health, Inc.
4801 E. Washington Street
Phoenix, AZ 85034
Phone: 1-800-424-3312
? 2017 每 2018, Magellan Health, Inc. All Rights Reserved.
Magellan Rx Management 每 Commercial Clients. Revision Date: 05/07/2018
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