MEDICATION PRIOR AUTHORIZATION REQUEST FORM
Peach State Health Plan, Georgia
(Do Not Us
e This Form for Biopharmaceutical Products*)
FAX
this completed form to 866-399-0929
OR Mail requests to: Envolve Pharmacy Solutions PA Dept. | 5 River Park Place East, Suite 210 | Fresno, CA93720
Call 800-460-8988 to request a 72-hour supply of medication.
Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information, except during
weekends and holidays. For immediate response on weekends and holidays, Nurse Advice Line will answer your call.
I. Provider Information
Prescriber name (print):
Prescriber Specialty:
Fax: Phone:
Office Contact Name:
II. Member Information
Member name:
Identification number:
Date of Birth:
Medication allergies:
III. Drug Information (One drug request per form)
Drug name and strength: Dosage form: Dosage interval (sig): Qty per Day:
Diagnosis relevant to this request:
Expected length of therapy:
Medication History for this Diagnosis
A. Is member currently treated on thismedication?
yes; How Long?
[go to item B]
no [skip items B & C; go to item D]
B. Is this request for continuation of a previous approval?
yes [go to item C] no [skip item C; go to item D]
C. Has strength, dosage, or quantity required per day increased ordecreased?
yes [go to item D] no [skip item D; indicate rationale for continuation in Section IV and submit form]
D. Please indicate previous treatment and outcomesbelow.
Drug Name (include strength anddosage) Dates of Therapy Reason f
or Discontinuation
1
2
3
4
NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Peach State Health Plan
Preferred Drug List (PDL) is available on the Peach State Health Plan website atwww.pshp.com.
IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)
Appropriate clinical information to support the request on
the basis of medical necessity must be submitted.
Provider Signature: Date:
Requests for prior authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports
with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine;
CD4; Hematocrit; WBC, etc.)
*Fax Biopharmaceutical/Specialty requests to Peach State Health Plan at 866-374-1579
OR call 800-514-0083, Option 2 forquestions.
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