Prescription Drug Prior Authorization Request Form 2018

CVS Caremark Mail Service Pharmacy. Providers may submit prior authorization requests to UPMC Health Plan online or by fax. Download and complete the Pharmacy Information Authorization form (13-835A) and send to 1-866-668-1214. New Uniform Prescription Drug Prior Authorization Request Form and Notification Requirements for Health Plans in California. Form 61-211. We work with your health care providers and pharmacists to make sure we cover the most important and useful drugs for a variety of conditions and diseases. These drug authorization forms are intended for our employer group plans and/or FAMIS members. Signature of physician Date Section 5: Drug covered by the authorization Drug name Pharmaceutical form Strength Dosage Dose: Frequency of administration: Type of request First request Continuation of treatment Complete section 6 Complete section 7. To initiate an electronic prior authorization (ePA) request, please click here. If originating at the pharmacy, the pharmacy must transmit the form to the prescriber for the justification, medical information, and the prescriber’s or authorized representative’s signature. If your request is urgent, it is important that you call us to expedite the request. Prior authorization has been a hot topic of debate in the healthcare industry for some time. cahealthwellness. Express Scripts, Inc. To view the summary of guidelines for coverage, please select the drug or drug category from the list below. Certain drugs require specific forms. Requesting an exception to the drug list.



Prior Authorization is required for all outpatient therapy services including PT, OT, and SLP. LACDMH Pharmacy Services/PBM Contacts LACDMH Pharmacy Services-PBM Contacts Pharmacy List Magellan's LACDMH Pharmacy Network (Rev. Destination of Request ‐ Insurer or pharmacy benefits manager (PBM) will pre‐populate Section A prior to making the form available on its website. How to Request a Coverage Determination. The Drug Authorization Request Form may be downloaded from an insurer’s website. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. All completed forms should be returned by fax. MedWatch form to justify the member’s need to avoid a generic product. 0 - 2018-12 Submitted to: Phone: Fax: Date: S LOUISIANA UNIFORM PRESCRIPTION DRUG PRIOR AUTHORIZATION FORM SECTION I — SUBMISSION ECTION II ― PRESCRIBER INFORMATION. Louisiana Uniform Prescription Drug Prior Authorization Form (Effective January 1, 2019) (PDF Format) This page contains the pharmacy Prior Authorization (PA) form for Fee-for-Service Medicaid and MCO plans. Hepatitis C Prior Authorization. Benefit designs may vary with respect to drug coverage, quantity limits, step therapy, days supply and prior authorization. If your request is urgent, it is important that you call us to expedite the request. The prior authorization process will involve the child's physician and pharmacist communicating with WVU's School of Pharmacy, Rational Drug Therapy Program (RDTP), about the situation, since these prior approvals are given on a case-by-case basis. A Step Therapy drug can be obtained without first trying a first step drug by submitting a Prior Authorization Form with documentation of existing medical need for consideration. MassHealth Prior Authorization Forms for Pharmacy Services MassHealth Drug List A - Z Open Monday-Friday 8 a. Prior Authorization Forms.



Medicare Part Prior Authorization for Hospice Form – CMS. Online: Request Prescription Drug Coverage; Fax or Mail: Complete a request for prescription drug coverage. Form 1335 Page 4 / 03-2018-E Please complete and fax all required documents to the Texas Prior Authorization Call Center at (800) 601-4829 for initial prior authorization requests. prior authorization forms for hmsa ppo. Also, by signing and submitting this request form, the prescriber attests to statements in the ‘Attestation’ section of the criteria specific to this request, if applicable. Please refer to the preferred drug list (PDL) when prescribing for these members. If the prescription drug is not covered, your provider may request an exception be made. 2851 to submit a verbal prior authorization request. Make sure preferred drugs have been tried first and that there is documentation supporting this. Additional Clinical Information – Please provide any other relevant clinical information to support the prior authorization review. CIGNA-HEALTHSPRING – Tennessee Chapter of the HFMA. PRIOR AUTHORIZATION requests may require supporting information. 2018 Prior Authorization State Law Chart. Confidential …. Drug Requests — Prior Authorizations, Exceptions & Appeals Initial/Renewal Prior Authorization & Exception Requests PHARMACY BENEFIT DRUGS. Requests that are subject to prior authorization (or. TennCare Portal by Magellan Health Services. prior authorization for either all or certain types of genetic tests (eight … prescription drug prior authorization or step therapy exception … www. Prior Authorization: The Current Landscape. Is the prescription for a drug to be administered in the office or for the member to take at home? office home.



All Medicare Part B authorization requests will need to be faxed to 1-866-959-1537. Medicaid Pharmacy Prior Authorization Programs Update - December 2018 Update on Medicaid Fee-for-Service Prior Authorization of Topical Compounded Drug Products (Cover) - November 2018 Medicaid Pharmacy Prior Authorization Programs Update (cover) - July 2018. Prior authorization for prescription drugs is required when your insurance company asks your physician to get specific medications approved by the insurance company. DME Prior Authorization Form Providers should use this form when requesting authorization for durable medical equipment. A request form must be completed for all medications that require prior authorization. The Global Prior Authorization policy was developed to protect the health of Health First Colorado's most vulnerable members. Advocacy Resource Center. medicare prescription drug benefit – CMS. North Carolina Division of Health Benefits North Carolina Medicaid and Health Choice Preferred Drug List (PDL) Effective: 01/31/2019 Trial and failure of two preferred drugs are required unless otherwise indicated. Opioid/Narcotic Prior Authorization Form Attn: Pharmacy Dept. If there are questions regarding prescription benefit coverage, please call the phone number on the back of the member's BCBSMT ID card. Absolute Total Care is committed to providing appropriate, high-quality, and cost-effective drug therapy to all Absolute Total Care members. In addition to detailed program information, you will find our policies and procedures, referral and claim information, and other useful reference materials that we hope will make working with our staff and members as simple as possible. If you do not see the name of the drug needing prior authorization listed below you will need to select the Miscellaneous Pharmacy Prior Authorization Request form. Also, by signing and submitting this request form, the prescriber attests to statements in the ‘Attestation’ section of the criteria specific to this request, if applicable. The Texas Medicaid program covers most outpatient prescription drugs either through a Medicaid managed care organization (MCO) or through VDP. Inpatient: Requests for changes to inpatient authorizations can be made via fax using our Inpatient TRICARE Service Request Notification form. Absolute Total Care covers prescription medications and certain over-the-counter medications with a written order from an Absolute Total Care provider. If no drug-specific form is available, please use the General Coverage Determination form.



Requests that are subject to prior authorization (or. Personal Choice 65 SM PPO members, the plan requires prior authorization (approval in advance) of certain covered prescription drugs that have been approved by the FDA for specific medical conditions. Patient address, city, state, ZIP. Depending upon the drug, either the prescribing physician or the dispensing pharmacist may submit the request. INTRODUCTION. Certain requests for coverage require review with the prescribing physician. Call the department’s Prior Approval hotline at 1-800-252-8942. Benefit designs may vary with respect to drug coverage, quantity limits, step therapy, days supply and prior authorization. Scope controls refer to constraints used to insure a drug is used for approved indications and is therapeutically appropriate. How to Request a Coverage Determination. Prescription Drugs Requiring Prior Authorization. Revised 12/2016. This is the fastest and easiest way to submit PAs. Phone: (877) 600-5472. We also require a supporting statement from the. medicare prescription drug benefit – CMS. How to submit a request for pharmacy prior authorization Online. December 2018: 340B Drug Pricing Program Expanding in 2019 Texas Standard Prior Authorization Request Form.



Prior Authorization: The Current Landscape. Prior Authorization List – Health First. Online: Request Prescription Drug Coverage; Fax or Mail: Complete a request for prescription drug coverage. Forms Reimbursement Forms. Medicaid Pharmacy Prior Authorization & Preferred Drug List Rev. Your doctor can request this drug by filling out a prior authorization request and sending it to Priority Partners. REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Anthem Blue Cross and Blue Shield. The appropriate drug prior authorization (PA) form may be located by using the drug search function (at the top of this page) or by selecting the first letter of the drug to be requested (from the A to Z list displayed above). (Drug and Dosage) Duration of Therapy (Dates) Reason for Failure 2. CIGNA-HEALTHSPRING – Tennessee Chapter of the HFMA. Get started at our online prior authorization request form or learn more in our tutorial. This means that members must receive approval from Health Net before a drug will be covered. Hospice Information for Medicare Part D Plans. Interim February 2019 - Utah Medicaid - Utah. If you are a member of the Retiree Benefit Plan, click here to access Retiree forms. | 5 River Park Place East, Suite 210 | Fresno, CA 93720. REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Anthem Blue Cross Cal MediConnect. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. PDF download: INSTRUCTIONS FOR COMPLETING FORM EC-2 Page 1 of 4 – EUTF. Prior Auth Criteria Search.



Subscriber ID Number. 5282 TDD Relay: 1. If your request is urgent, it is important that you call us to expedite the request. com and use electronic Prior Authorization (ePA). Hepatitis C Prior Authorization Request Form - Effective January 1, 2019 (Revised December 2018) Hepatitis C Treatment Outcomes; Global Prior Authorization. Form 61-211. If you currently take a prescription drug not on the formulary, contact customer service to make sure the drug is not covered. View our Prescription Drug List and Coverage Policies online at. View Our Prior Authorization Guidelines. An exception is a type of coverage decision. Instructions. Medicare Part D Coverage Determination Request Form. Help your patients by prescribing only generic and preferred brand-name drugs on the Fund’s Preferred Drug List. Medicaid Prior Authorization Request Form for Prescriptions. chart notes, medication history, lab results, etc. Page 2 of 2 Revised 12/2016 Form 61-211 PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM Patient Name: ID#: Instructions: Please fill out all applicable sections on both pages completely and legibly. The Global Prior Authorization policy was developed to protect the health of Health First Colorado's most vulnerable members. Authorizations reviewed by Amida Care: The prior authorization request forms below will be reviewed by Amida Care. OR Mail requests to: Envolve Pharmacy Solutions P A Dept.



Prescription Drug Prior Authorization or Step Therapy Exception Request Form (61-211) Pursuant to Senate Bill 282 and Assembly Bill 374, the DMHC and the Department of Insurance developed a mandatory prescription drug prior authorization or step therapy exception request form. £ I request prior authorization for my prescription. 2212c, requires the use of a standard prior authorization form when a policy, certificate or contract requires prior authorization for. Requesting an exception to the drug list. Requests that are subject to prior authorization (or. Allow us at least 24 hours to review this request. December 2018: 340B Drug Pricing Program Expanding in 2019 Iowa Community Plan Pharmacy Prior Authorization Forms; Louisiana Community Plan Pharmacy Prior. The Fidelis Prior Prescription (Rx) Authorization Form allows a prescribing physician to request coverage for a prescription drug. Express Scripts, Inc. Prior Authorization Form for Medical Procedures, Courses of Treatment, or Prescription Drug Benefits 69O-161. Prior authorization must be provided before the insurance company will provide full (or any) coverage for those medications. IMPORTANT: Please answer all questions. For information about pharmacy-related prior authorization, see the Pharmacy Services module. Help your patients by prescribing only generic and preferred brand-name drugs on the Fund’s Preferred Drug List. 00 for formulary brand prescription drugs Copays will apply to any approved prior authorization for a non-formulary drug Medications within the following specified therapeutic categories will be excluded from the. Questions and Answers. The unit also oversees the Pharmaceutical and Therapeutics Committee and Drug Utilization Review Board and maintains the Medicaid Preferred Drug List. Subscriber ID Number. You are at: Home For Providers Pharmacy Prior Authorization Request Forms and Order Forms.



) this authorization, it will not affect prior. Inpatient: Requests for changes to inpatient authorizations can be made via fax using our Inpatient TRICARE Service Request Notification form. San Antonio, TX 78265-8686. Prior Authorization: The Current Landscape. Express Scripts, Inc. Prior authorization — If your plan requires prior authorization for a medication you are taking, you or your doctor will need to contact the plan before you can fill your prescription. Please complete the prescription prior authorization form and fax it to us at 1‑858-357-2534. Patient address, city, state, ZIP. prescription drug prior authorization request form – Health Net. Oct 16, 2015 …. 02/2018 pol-mpapdl TxVendorDrug. Hepatitis C Prior Authorization Request Form - Effective January 1, 2019 (Revised December 2018) Hepatitis C Treatment Outcomes; Global Prior Authorization. PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM. treatment in a substance abuse treatment program as defined in Utah State Code. Destination of Request (This section is to be completed by insurers/PBMs/UREs prior to making form available). For additional information regarding Prior Authorization and Health Case Management, please visit our Great-West Life website at www. Prior Authorization Program Review and Volume Adjustment. 2212c, requires the use of a standard prior authorization form when a policy, certificate or contract requires prior authorization for. require prior authorization.



Depending upon the drug, either the prescribing physician or the dispensing pharmacist may submit the request. PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM Plan/MedicalGroup Name: Medi-Cal L. This is called prior authorization. Drug Name (select from list of drugs shown …. PDF download: INSTRUCTIONS FOR COMPLETING FORM EC-2 Page 1 of 4 – EUTF. By signing this request, the prescriber attests that the information provided herein is true and accurate to the best of his/ her knowledge. 2212c, requires the use of a stand ard prior authorization form when a policy, certificate or contract requires prior authorization for. Why Do Insurance Companies Require Prior Authorization?. health plan/insurer preferred drug. * medicare easy pay authorization agreement form medicare 2018 * medicare express scripts medication prior authorization form medicare 2018 * medicare fax number for prior authorization medicare 2018 * humana medicare prior authorization form 2016 * molina market place prior authorization * molina marketplace drug prior authorization form wi. Preferred Drug List 3rd Quarter, 2018 Updates (September 2018) (PDF) Preferred Drug List 2nd Quarter, 2019 Updates (PDF) Buckeye Health Plan (BHP) routinely reviews their Prior Authorization (PA) and Medical Necessity (MN) criteria. When a PA is needed for a prescription, the member will be asked to have the physician or authorized agent of the physician contact our Prior Authorization Department to answer criteria questions to determine coverage. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist. Step therapy is another form of a prior authorization, but. Also view our list of Step Therapy guidelines. Care Health Plan Plan/MedicalGroup Phone#: (844) 268-9786. Page 1 of 2 Version 1. If we approve the request, payment is still subject to all general conditions of Anthem Blue Cross and Blue Shield, including current member.



Instruction Sheet for New Hampshire Uniform Prior Authorization Form for Prescription Drug Requests A. April 2018. Fax completed forms. The Division of Medicaid recommends that prescribers use the drugs on the Preferred Drug List (PDL). Application for MS Family Planning Services (PDF) CHIP Reconsideration and Dispute Form (PDF) Connections Referral Form (PDF) Discharge Consultation Documentation Form (PDF) Hospice Physician Form (PDF) New Prior Authorization Forms (PDF) CHIP Inpatient Prior Authorization Form (PDF). Minnesota Health Care Programs (MHCP) Drug Prior Authorization Form This form is for requesting prior authorization for outpatient drugs dispensed at a pharmacy. Submitted to IEHP on 11/04/2016 8:41AM. Requests must include clinical documentation that supports the medical need for the specific medication. If you have questions regarding a Medicaid prior authorization request, call us at 1-800-454-3730. The pharmacy is authorized to dispense up to a 72-hour. Requests that are subject to prior authorization (or. We list drugs that require step therapy with an “ST” notation. More resources that may help you. This form is to be completed by the prescribing provider and staff. ☐I want to be reimbursed for a covered prescription drug that I paid for out of pocket. Find all the information you need to manage your patients' prescription drugs, including formularies, prior authorization forms, drug quantity limits, and more. Please reference your plan's formulary for a list of drugs that require prior authorization. New Uniform Prescription Drug Prior Authorization Request Form and Notification Requirements for Health Plans in California. As a result of Public Act 097-0689 (pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, the department must develop utilization controls, including prior approval, for specialty drugs, oncolytic drugs, drugs for the treatment of HIV or AIDS, immunosuppressant drugs, and biological products in order to maximize savings on these drugs. Destination of Request ‐ Insurer or pharmacy benefits manager (PBM) will pre‐populate Section A prior to making the form available on its website.



Please use the search function or select View All to locate the drug specific Peach State Health Plan prior authorization form that should be used when submitting an authorization request. • Print the response. (Drug and Dosage) Duration of Therapy (Dates) Reason for Failure 2. You can now submit your PAs for prescription drugs through Express PAth, Express Scripts' PA portal. pdf arkansas medicaid prescription drug program statement of medical necessity- prior authorization request form. Check One: Drug dispensed from a pharmacy (Pharmacy Benefit) Drug administered in an office or outpatient setting (Medical Benefit). Step therapy is another form of a prior authorization, but. Attach any additional documentation that is important for the review (e. To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. Starting July 15, 2002 all new prescriptions for CCHP patients (except permanent County employees) must be taken from our PDL formulary or be accompanied by a Medication Prior Authorization Request (PA) form. The Cigna-HealthSpring prior authorization list is available on our website. form to 1-800-359-5781. Download Fillable Form 61-211 In Pdf - The Latest Version Applicable For 2019. 2212c, requires the use of a stand ard prior authorization form when a policy, certificate or contract requires prior authorization for. Application for MS Family Planning Services (PDF) CHIP Reconsideration and Dispute Form (PDF) Connections Referral Form (PDF) Discharge Consultation Documentation Form (PDF) Hospice Physician Form (PDF) New Prior Authorization Forms (PDF) CHIP Inpatient Prior Authorization Form (PDF). All Medicare Part B authorization requests will need to be faxed to 1-866-959-1537. org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Provider Pharmacy Prior Authorization Forms are located on the Provider Resources Forms page, under Prior Authorization Forms. Instructions for Physician Administered Drug Prior Authorization: Please check posted criteria before submitting a prior authorization request (see links below). If any items on the Eon Prior Authorization List are submitted for payment without obtaining an.



i Care authorizes outpatient therapy by number of visits; however, the CPT codes that the provider anticipates billing MUST be listed on the prior authorization request form in order tocomplete the clinical review and determine medical necessity. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. North Carolina Division of Health Benefits North Carolina Medicaid and Health Choice Preferred Drug List (PDL) Effective: 01/31/2019 Trial and failure of two preferred drugs are required unless otherwise indicated. Download and complete the Pharmacy Information Authorization form (13-835A) and send to 1-866-668-1214. Provider Pharmacy Prior Authorization Forms are located on the Provider Resources Forms page, under Prior Authorization Forms. This form will be returned if not completed in full. Learn about prior authorization, how to find out if a drug is billed as a medical or pharmacy benefit, and how to request a review for coverage of a drug that isn't included in your plan. Attach any additional documentation that is important for the review, e. Prior authorization for prescription drugs is required when your insurance company asks your physician to get specific medications approved by the insurance company. Plan/ Medical Group Name: …. Doctors also can call OptumRx directly at 1-855-577-6550 to request a PA/exception. Some prescription drugs require a prior authorization. When a claim returns the NCPDP request code 75 ("Prior Authorization Required”), a prior authorization is needed. ZappRx has developed a digital specialty medication prescription and prior authorization platform. Hospice Information for Medicare Part D Plans. If a form for the specific medication cannot be found, please use the Global Prior Authorization Form. For fax requests.



Prescription Drug Prior Authorization Request Form. To control drug costs and reduce the use of expensive medications, insurers have long relied on step therapy, a restriction on insurance coverage that requires patients to prove that less-expensive drugs are ineffective before getting coverage for a more expensive, higher-tier drug. Online PA request form ; Louisiana uniform prescription drug PA request form; Prescribers may also request PA medications by calling the PerformRx℠ Provider Services Help Desk at 1‑800. * ☐I have been using a drug that was previously included on the plan's list of covered drugs, but is. H2563_SEN_2019 D Cov Det Request_DSNP_C 1 REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to OptumRx (pharmacy benefit manager for Optima Community Complete (HMO SNP)) by mail or fax: Address: Fax Number: OptumRx 1-866-511-2202 Attn: Prior Authorization Part D P. To receive that approval, you and/or your doctor or other prescriber must complete and submit a Prior Authorization. Beginning September 1, 2015, health benefit plan issuers must accept the Texas Standard Prior Authorization Request Form for Health Care Services if the plan requires prior authorization of a health care service. REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Anthem Blue Cross and Blue Shield. Did you know that around half the prior authorizations we receive each month are electronic and growing fast? It may be time for you to make the switch to electronic prior authorization (ePA). Authorization Request for Inpatient and Outpatient ServicesProviders should use this form when requesting authorization for a procedure to be performed in an IP/OP or OBS setting. This form cannot be used to request:. Prescription Drugs; Prior Authorization Forms; Pharmacy & Therapeutics Committee. Non-Formulary Drug Prior Authorization Form — Use this request form if the medication you want to request does not have an associated drug-specific form. 61-211) is attached. Prior Authorization Request Form Please fax completed form to 570-300-2122, 570-271-5610, or 855-214-1500. Providers may submit requests for approval via fax, phone or the NCTracks secure prior authorization portal. Effective 01/01/2019. Prior authorization for prescription drugs is required when your insurance company asks your physician to get specific medications approved by the insurance company. The form is also available on the Provider Resources webpage at www. Registered Users If you are a Mississippi Medicaid prescriber, submit your prior authorization requests through the Change Healthcare provider portal.



pacificare prior authorization forms. DHHS Bulletins; DHHS Medical Necessity; DHHS Pharmacy; DHHS Provider Handbooks; Drug. You may also ask us for a coverage determination by phone at 1-833-293-0661 (TTY users can. Click here for information on obtaining an Emergency PA for medications. This form cannot be used to request:. To submit a request for medications that will be administered by a provider (i. Authorization of Representation Form CMS-1696 or a written equivalent). We also require a supporting statement from the. This form cannot be used to request. A request must be submitted and approved in advance for medications requiring a prior authorization, before the drugs may be covered by Humana. If your request is urgent, it is important that you call us to expedite the request. Prescription Drug Prior Authorization or Step Therapy Exception Request Form Author: Blue Shield of California Subject: Prescription Drug Prior Authorization or Step Therapy Exception Request Form Keywords: Prescription Drug Prior Authorization or Step Therapy Exception Request Form; Blue Shield of California; MAPD Created Date: 9/20/2018 10:23. non-formulary drugs your provider would have to submit a regular Prior Authorization request. 4/2019) DMH Formulary DMH Formulary September 2018 Prior Authorization Request NEW PA Request Form (Rev 02/2018) NEW ODT PA Request Form (Rev. All drugs on these lists are approved by the Food and Drug Administration (FDA). If you do not see the name of the drug needing prior authorization listed below you will need to select the Miscellaneous Pharmacy Prior Authorization Request form. specialty, home health, outpatient, injectable or infusible medications), use the form below. Minnesota prescribers, please use the Minnesota State PA Request Form for prescription drug prior authorization (PA) request and formulary exceptions. Please provide any additional clinical information or comments pertinent to this request for coverage (e. San Antonio, TX 78265-8686.



Quantity Limit Override Age Override Non-Preferred Clinical Criteria Other _____. Your doctor can submit a Prior Authorization Form to request approval for a drug that is not on the Preferred Drug List or a prescription requires review. PDF download: request for medicare prescription drug coverage … – SilverScript. MassHealth Prior Authorization Forms for Pharmacy Services MassHealth Drug List A - Z Open Monday-Friday 8 a. Section 2212c of Public A ct 218 of 1956, MCL 500. Our drug lists identify which drugs require prior authorization. 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. We use it to make sure your prescription drug is: Safe ; Effective ; Medically necessary Click to close To be medically necessary means it is appropriate, reasonable, and adequate for your condition. To submit a request: Select and print the proper form from the list below; Fill out the form completely; Fax the completed form to us at 1-888-879-6938; OR. Fill out a prior authorization form. Some medications may require prior authorization and some may have limitations. 011 OIR-B2-2180 New 12/16 ActiveHealth Management, Inc. Here's why: Faster to send and get reviews; Easier to use for prescribers, nurses and office staff; Works for any prescription drug and any pharmacy. Louisiana Uniform Prescription Drug Prior Authorization Form (Effective January 1, 2019) (PDF Format) This page contains the pharmacy Prior Authorization (PA) form for Fee-for-Service Medicaid and MCO plans. This is called prior authorization. Unless the patient resides in Texas, Colorado, or California, or if they are a Medicare member, the general prior authorization form can be administered. If you are unable to use our website, please call us at 800. chart notes or lab data, to support the prior authorization request. Drug inducted neutropenia (ganciclovir or. Prescription Drug Prior Authorization Request Form 2018.