|
|
| |
|
Helpful Hints Passport Health Plan Drug Prior Authorization
Request
|
Purpose of Form
The purpose of the form is to request that the Plan approve
a medication that is not on the Plans non-prior-authorization
list.
Completing the Form
|
| |
|
| First Section |
Prescriber and Member Information. Please include ALL
requested prescriber and member information.
|
| |
|
| Second Section |
Requested Medication Information.
Please check whether this is a NEW or RENEWAL request for
this medication. Please include all requested information. |
| |
|
| Third Section |
PCN/PLAN reply information. Do
NOT write in this box. |
| |
|
Two of the most common reasons
for denials are:
1. Incomplete Forms
2. Illegible Forms |
| |
|
Distributing the Form
|
| Here is a quick reference guide for the appropriate
distribution channels: |
| |
|
| Fax |
Pharmaceutical Care Network (PCN) at (800) 945-1815
|
| |
|
| Urgent Request |
Place a check next to URGENT
REQUEST at the top of form. Explain reason for urgency under
second section of the form (urgent fax line is reserved
for requests that in the providers best professional
judgment are potentially life threatening or pose a significant
risk to the continuous care of the patient). Fax to urgent
fax line (877) 636-9001. |
Customer Help
|
| If you need assistance with this form call: |
| |
Customer Service Help Desk
(800) 777-0074 |
|
| |
| |
|