Download PacifiCare Non Formulary Medication Prior

PacifiCare Non Formulary Medication
Prior Authorization Form
DATE: _______
TIME: _______
MOD: III
Patients Name: ________________________________
Physician Name: _______________________________
Specialty: _______________________________
Address: _______________________________
_______________________________
Phone #: (______)________________________
Member #: ________________________________
Phone #: (______)_________________________
Date of Birth: ________________________________
Male
Female
FAX #:
(______)________________________
Strength:
Requested Medication:
Directions For Use:
DIAGNOSIS:
Date Patient Started this Medication:
NAME OF SPECIFIC DRUGS TRIED AND FAILED:
Reason For Non-Formulary Request. ( Patient chart notes will be requested if further documentation is necessary )
Date:
Requesting Physician Signature:
Office Use Only
Approved
Denied
Date Received :
Date Received :
Date Reviewed:
Date Reviewed:
Approval Dates:
to
Reason Denied:
Signature:
PC #: 1 2 3 4 5
Physician notified _______:_______ am/pm
Carrier/Acct: _______________________________
Employer Group: ___________________________
1) To Prescriber- Complete and return to:
Signature:
Office Use Only
Plan Code: ____________________________
Facility ID: ____________________________
Prescription Solutions
3515 Harbor Blvd.
Costa Mesa, CA 92626
Phone # : 1-800-711-4555
Fax # : 1-800-527-0531
2) Obtain Member’s Pharmacy Name and Phone number.
3) Instruct member to call prescriber in three (3) working days of request to check approval. If this request is for an acute
medication, please call 1-800-711-4555.
4) Prescription Solutions will contact prescriber with decision or request for additional information.
5) Once approval is received, prescriber calls in prescription to member’s pharmacy
6) Authorization will be granted for up to twelve (12) months unless otherwise noted.
Request for Missing/Additional Information Form
Request for Missing/Additional Information
Your request for Prior Authorization for the patient listed above is incomplete and cannot
be processed as a Prior Authorization request until additional information has been
provided. In order to ensure rapid patient care and to expedite appropriate medication
consistent with the member’s benefit, we need the following pertinent information.
Patient name
Directions for Use
Member #
Diagnosis
Date Birth
Name of specific drugs tried and failed
Requested Medication
Reason for non-formulary request
Requesting physician signature/contact name
Additional drug specific information. Complete questions on the following page related
to the item number indicated below.
1
2
3
4
5
6
As part of your contract with PacifiCare, it is important to provide complete clinical
information when requesting prior authorization for non-formulary drugs. Please record the
requested information in the space provided on the top half of this form, and/or the drug
specific information on the next page and then fax back the request to: 800-527-0531. Or,
to expedite the resolution of the requested medication, call 800-711-4555. Note: If
complete information is not returned within 48 hours, a denial will be issued. Once
complete information is received, a decision will be rendered.
Request for Drug Specific Information
1OSTEOPOROSIS
1.
DRUGS:
Evista
Fosamax
Miacalcin
2.
3.
Member Name:
Member ID #:
Bone Mineral Density/Scan (DEXA or QCT) Date:______ Result:
Standard deviation below young adult mean: ____________
Is patient currently on ERT? Yes____ No____
gm/cc
Does patient have a contraindication for ERT? Yes____ No____
If yes,
What is the cause ?
________________________________
_________________________
4. Does patient have a history of vertebral compression fractures?
Yes____ No____
2
DRUGS:
Aricept
Cognex
5.
Does patient have a history of hip or distal radius fractures resulting from
minimal trauma? Yes___ No___
6.
Is the patient receiving concurrent chronic or expected oral steroid use?
Yes
No If yes,
What dose and for how long?
_________________________________________________
ALZHEIMERS
1.
Current Mini-Mental Status Exam (MMSE) Score:_______ Date:
2.
If score is 10 or 11, in which of the following categories does the
patient exhibit independence?
Transferring
Continence
Feeding
Bathing
Dressing
Going to toilet
3 HYPERLIPIDEMIA
1.
DRUGS:
Lescol
Lipitor
Mevacor
Pravachol
Zocor
2.
Lipid Panel information: Baseline date:_________________ Current
date:
TC
TC
TG
TG
LDL
LDL
HDL
HDL
Goal of therapy i.e. LDL < 100 ________________ Current
drug and dose
Does patient have any of the following CHD or CAD risk factors?
HDL Cholesterol < 35
Diabetes
Hypertension
Smoking
Female w/ premature menopause and not on ERT
4 PPI’S
DRUGS:
Aciphex
Prevacid
Prilosec
Female > 55 years old
Male > 45 years old
1.
Is this initial therapy? Yes____ No____. If no, how long has the patient
been on the drug? ______________
2.
For continuation of therapy, What are the clinical reasons?
3.
Has step down therapy been tried? Yes____ No ____ If no, list reasons
why
4.
Has PPI been prescribed by GI consult for long term therapy? Yes____
No ____
5.
Patient has diagnosis of
Zollinger-Ellison Syndrome
Esophagitis
Stomach Cancer
Grades III / IV Esophagitis
Esophageal Stricture
Gastropathy
Other malignancies
Barrett’s
NSAID