Read Microsoft Word - Generic PA Form_May 2010_Rebranding.DOC text version

SOUTH CAROLINA MEDICAID PROGRAM

PRIOR AUTHORIZATION REQUEST PRESCRIBER:

NAME: __________________________________

(FIRST) (LAST)

BENEFICIARY:

NAME:

_________________________________

(FIRST) (LAST)

National Provider ID #________________________ PHONE # (______)______________ FAX # (______)______________

MEDICAID #: _______________________________ DATE OF BIRTH: ____/____/____ SEX: REQUEST DATE: ____/____/____ M F

PRESCRIBER'S OFFICE STAFF MEMBER COMPLETING FORM: _____________________________________________

PHARMACY: _______________________________________

PHONE: (______)_________________________

PRIOR AUTHORIZATION REQUESTED FOR: (Please check appropriate prior authorization type) Quantity Limits NOTE: Orlistat (please include information

regarding height, weight, diet plans, nutritional counseling, etc., with all orlistat requests)

PDE5 Inhibitor for Pulmonary Arterial Hypertension Other: ____________________

"Brand Medically Necessary" PA requests require a South Carolina MedWatch form. "Growth Hormone" PA requests require a Growth Hormone request form.

DRUG NAME

DOSE

STRENGTH

LENGTH OF THERAPY

DIAGNOSIS: ______________________________________________________________________________________ DIAGNOSTIC PROCEDURES AND FINDINGS (please list dates): ________________________________________ ___________________________________________________________________________________________________ MEDICAL JUSTIFICATION FOR PRODUCT USE: ____________________________________________________ ___________________________________________________________________________________________________ PRESCRIBER'S SIGNATURE AND SPECIALTY: ______________________________________________________

MAGELLAN MEDICAID ADMINISTRATION USE ONLY: DATE: ______/______/________ MAP RPh/TECH: _________________________ NDC: ___________________________________ APPROVED DENIED

COMMENTS: __________________________________________ ________________________________________________________ ________________________________________________________

SUBMIT REQUESTS TO: MAGELLAN MEDICAID ADMINISTRATION FAX: (888) 603-7696 All Fax requests will be processed in one business day To check on the status you may call TELEPHONE: (866) 247-1181 WEB REQUESTS: PA's may be requested on-line see the following website for details: http://southcarolina.fhsc.com/

Revised: May 2010

General PA Form

Information

Microsoft Word - Generic PA Form_May 2010_Rebranding.DOC

1 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

187724


You might also be interested in

BETA
Layout 1
Microsoft Word - Generic PA Form_May 2010_Rebranding.DOC
Microsoft Word - 2012-01-01 OH JFS Provider Manual FINAL.docx
Medicaid & CHIP