Read Humana-2011_PriorAuthorization.pdf text version

PRIOR AUTHORIZATION REQUEST FORM

EOC ID: Administrative Product - Universalr

rPhone: 800-555-2546 Fax back to: 1-877-486-2621

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HUMANA INC manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. For Medicare PFFS members, prior authorization is not required for Part B-covered medications. The information below is needed for a Part B versus Part D determination for these members.

Patient Name:NA Member/Subscriber Number: Date of Birth: Group Number: Address: City, State ZIP:

Prescriber Name:NA Fax: Office Contact: NPI: Address: City, State ZIP: Specialty/facility name (if applicable): Tax ID#: Phone:

Drug Name: Directions/SIG: Qty:

rExpedited/Urgent Please read if expedited request: By signing below, I certify that applying the standard 72-hour review time frame may seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function. Signature:_______________________

Please attach any pertinent medical history or information for this patient that may support approval. Please answer the following questions and sign:

Q1. Please provide J-code, if applicable:

Q2. Please provide ICD-9 code:

Q3. Is the medication being requested for use in an ongoing investigational trial? Yes No

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Q4. Please provide diagnosis:

Q5. Please list therapeutic alternatives previously used with start/end dates and outcome:

Prescriber Signature

Date

This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for the return of this document.

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