Form FA-59 Prior Authorization - Nevada

Form FA-59 or the "Prior Authorization" is a form issued by the Nevada Department of Health and Human Services.

Download a PDF version of the Form FA-59 down below or find it on the Nevada Department of Health and Human Services Forms website.

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Prior Authorization Request
Nevada Medicaid - OptumRx
Pharmacy Authorization
Submit fax request to: 855-455-3303
Purpose: For the prescribing physician to request prior authorization, when required, for a drug on the Preferred Drug List
(PDL). Do not use this form for non-preferred drugs or drugs that have their own respective prior authorization forms. For
a list of drug-specific prior authorization forms, please visit the Nevada Medicaid pharmacy website at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.
DATE OF REQUEST:
RECIPIENT INFORMATION
Last name, First name, Middle initial:
Date of birth:
Recipient ID:
Gender:
Male
Female Phone:
PRESCRIBING PROVIDER INFORMATION
Name:
NPI:
Phone:
Fax (required):
Person to contact regarding this request:
REQUESTED DRUG
Generic substitution not permitted
Name:
Strength:
Dosage:
Duration:
PREVIOUS THERAPY
Strength:
Name:
Dosage:
Duration:
CLINICAL INFORMATION
Diagnosis and ICD-10 code (if applicable), diagnostic procedures and findings (include dates):
Medical justification for product use:
PROVIDER CERTIFICATION –
Prescriber’s signature and date required.
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by
Nevada Medicaid.
Prescriber’s Signature:
Date:
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions,
coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is
privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the
employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this
communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.
FA-59
05/11/2017 pv11/19/2013
Page 1 of 1
Prior Authorization Request
Nevada Medicaid - OptumRx
Pharmacy Authorization
Submit fax request to: 855-455-3303
Purpose: For the prescribing physician to request prior authorization, when required, for a drug on the Preferred Drug List
(PDL). Do not use this form for non-preferred drugs or drugs that have their own respective prior authorization forms. For
a list of drug-specific prior authorization forms, please visit the Nevada Medicaid pharmacy website at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.
DATE OF REQUEST:
RECIPIENT INFORMATION
Last name, First name, Middle initial:
Date of birth:
Recipient ID:
Gender:
Male
Female Phone:
PRESCRIBING PROVIDER INFORMATION
Name:
NPI:
Phone:
Fax (required):
Person to contact regarding this request:
REQUESTED DRUG
Generic substitution not permitted
Name:
Strength:
Dosage:
Duration:
PREVIOUS THERAPY
Strength:
Name:
Dosage:
Duration:
CLINICAL INFORMATION
Diagnosis and ICD-10 code (if applicable), diagnostic procedures and findings (include dates):
Medical justification for product use:
PROVIDER CERTIFICATION –
Prescriber’s signature and date required.
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by
Nevada Medicaid.
Prescriber’s Signature:
Date:
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions,
coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is
privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the
employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this
communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.
FA-59
05/11/2017 pv11/19/2013
Page 1 of 1

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