"Prior Authorization/Formulary Exception Request Fax Form - Health Net"

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Prior Authorization / Formulary Exception Request Fax Form
FAX TO: (800) 977-8226
Form must be fully completed to avoid a processing delay.
For status of a request, call: (800) 867-6564
Patient’s Name (Last, First, MI)
Date of Birth ------------------- MM / DD / YYYY -------------------
/
/
Member ID # ------------ Please print clearly and enter one digit per box -------------
Patient’s Phone ----------- Please print clearly and enter one digit per box -----------
(
)
Patient’s Address, City, State, Zip
Gender
Allergies
M
F
Provider’s Name (Last, First, MI)
Provider Specialty
Contact Name
Provider’s Address, City, State, Zip
NPI #
------- Provider’s Phone ----- Please print clearly and enter one digit per box -------
-------- Provider’s Fax ------- Please print clearly and enter one digit per box --------
(
)
(
)
Medication Name and Strength
Quantity
Direction for Use and Duration
Administered:
Doctor’s Office
Dialysis Center
Home Health
By Patient
Other (specify):
Diagnosis
ICD Code
New Start with This Medication:
Yes
No
If No, Date of First Dose
Medications Previously Tried with Dates of Use
Medical Justification and Supporting Information (attach labs and/or chart notes as appropriate)
For Commercial members for injectable drugs only:
Are you the patient’s primary care physician?
Yes
No
Has the patient provided an authorized referral?
Yes
No
Utilization Management Authorization # (attach copy):
The patient will obtain the medication from: The Provider
A Pharmacy
For Medicare members only: Please review carefully and complete each applicable subsection.
For all requests: Is the patient currently receiving dialysis?
Yes
No
For drugs considered to be High Risk Medications (HRM) for the elderly (i.e. drugs on Yes
Comment:
the Beers List), is the patient continuing on this medication without adverse effects?
No
For immunosuppressive medication requests:
If Yes, Date
Is it being used for a transplant? Yes
No
of transplant:
For antiemetic medication requests:
Will this drug be used as full therapeutic replacement for intravenous antiemetic
Will the patient be on any other concurrent antiemetic therapy? Yes
No
drugs within 2 hours and continued for a period not to exceed 48 hours of
Specify drug(s) & route: _______________________________________________
chemotherapy?
Yes
No
For nutritional supplement (enteral or parenteral) medication requests: Does the patient have a G-tube?
Yes
No
Does the patient have a permanent dysfunction of the digestive track?
Yes
No
I certify that the above information is correct to the best of my knowledge.
Physician’s Signature
Date
Name of provider/vendor submitting this form if other than the prescriber above
Phone #
The documents accompanying this facsimile transmission may contain information that is confidential and prohibited from disclosure. If you are not the intended recipient, you are hereby notified
that any disclosure, copying, distribution or use of the information contained in this transmission is strictly prohibited. If you have received this transmission in error, please notify the sender
immediately by telephone or by return FAX and destroy this transmission, along with any attachments.
Mailing Address: HNPS Prior Authorization Department, 10540 White Rock Road #280, Rancho Cordova, CA 95670
For copies of prior authorization forms and guidelines, please call (800) 867-6564 or visit the provider portal at www.healthnet.com.
Revised 08-2015
Prior Authorization / Formulary Exception Request Fax Form
FAX TO: (800) 977-8226
Form must be fully completed to avoid a processing delay.
For status of a request, call: (800) 867-6564
Patient’s Name (Last, First, MI)
Date of Birth ------------------- MM / DD / YYYY -------------------
/
/
Member ID # ------------ Please print clearly and enter one digit per box -------------
Patient’s Phone ----------- Please print clearly and enter one digit per box -----------
(
)
Patient’s Address, City, State, Zip
Gender
Allergies
M
F
Provider’s Name (Last, First, MI)
Provider Specialty
Contact Name
Provider’s Address, City, State, Zip
NPI #
------- Provider’s Phone ----- Please print clearly and enter one digit per box -------
-------- Provider’s Fax ------- Please print clearly and enter one digit per box --------
(
)
(
)
Medication Name and Strength
Quantity
Direction for Use and Duration
Administered:
Doctor’s Office
Dialysis Center
Home Health
By Patient
Other (specify):
Diagnosis
ICD Code
New Start with This Medication:
Yes
No
If No, Date of First Dose
Medications Previously Tried with Dates of Use
Medical Justification and Supporting Information (attach labs and/or chart notes as appropriate)
For Commercial members for injectable drugs only:
Are you the patient’s primary care physician?
Yes
No
Has the patient provided an authorized referral?
Yes
No
Utilization Management Authorization # (attach copy):
The patient will obtain the medication from: The Provider
A Pharmacy
For Medicare members only: Please review carefully and complete each applicable subsection.
For all requests: Is the patient currently receiving dialysis?
Yes
No
For drugs considered to be High Risk Medications (HRM) for the elderly (i.e. drugs on Yes
Comment:
the Beers List), is the patient continuing on this medication without adverse effects?
No
For immunosuppressive medication requests:
If Yes, Date
Is it being used for a transplant? Yes
No
of transplant:
For antiemetic medication requests:
Will this drug be used as full therapeutic replacement for intravenous antiemetic
Will the patient be on any other concurrent antiemetic therapy? Yes
No
drugs within 2 hours and continued for a period not to exceed 48 hours of
Specify drug(s) & route: _______________________________________________
chemotherapy?
Yes
No
For nutritional supplement (enteral or parenteral) medication requests: Does the patient have a G-tube?
Yes
No
Does the patient have a permanent dysfunction of the digestive track?
Yes
No
I certify that the above information is correct to the best of my knowledge.
Physician’s Signature
Date
Name of provider/vendor submitting this form if other than the prescriber above
Phone #
The documents accompanying this facsimile transmission may contain information that is confidential and prohibited from disclosure. If you are not the intended recipient, you are hereby notified
that any disclosure, copying, distribution or use of the information contained in this transmission is strictly prohibited. If you have received this transmission in error, please notify the sender
immediately by telephone or by return FAX and destroy this transmission, along with any attachments.
Mailing Address: HNPS Prior Authorization Department, 10540 White Rock Road #280, Rancho Cordova, CA 95670
For copies of prior authorization forms and guidelines, please call (800) 867-6564 or visit the provider portal at www.healthnet.com.
Revised 08-2015