This form is based on Express Scripts standard criteria and may not be applicable to all patients; certain plans and situations may require additional information beyond what is specifically requested.

PRIOR AUTHORIZATION REQUEST FORM Complete ENTIRE form and Fax to: 866-940-7328 ... Physician Signature: ___________________________________________ Date: …

I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on …

I understand that Prior Authorizations will not exceed 6 months from date of fill for controlled medications and 1 year for non-controlled medications, except for Early Refill Requests, which are valid one time …

Please attach or include a letter of Medical Necessity along with supporting documentation (e.g. chart notes, lab results, etc.) to assist in the prior authorization process and fax to Magellan Arkansas …

PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Patient Name: ID#: sections on both pages completely and legibly. Attach any additional documentation that is important for the …

MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, …

Is the request for a patient with one or more chronic conditions (e.g., psychiatric condition, diabetes) who is stable on the current drug(s) and who might be at high risk for a significant adverse event with a …

Molina Washington Prior Authorization Form27031WA0812

MassHealth reviews requests for prior authorization on the basis of medical necessity only. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, …