Fillable Prescription Drug Prior Authorization Form MEMBER INFORMATION

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Prescription Drug Prior Authorization Form MEMBER INFORMATION

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The Prescription Drug Prior Authorization Form MEMBER INFORMATION form is 4 pages long and contains:

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Prescription Drug Prior Authorization Form
Fax this form to: 1-800-424-3260
A fax cover sheet is not required.
© 2017–2021, Magellan Health, Inc. All rights reserved. MHID: MRXCOM01_01
Magellan Rx Management – Commercial Clients Revision Date: 01/01/2021 Page 1 of 4
Instructions: Please fill out all applicable sections on all pages completely and legibly. Attach any
additional documentation that is important for the review (e.g., chart notes or lab data, to support the
prior authorization). Information contained in this form is Protected Health Information under HIPAA.
NON-URGENT EXIGENT CIRCUMSTANCES
MEMBER INFORMATION
Member’s Last Name: Member’s First Name:
Date of Birth: Phone Number:
–
–
–
Member’s Address:
City: State: ZIP:
Sex: Male Female Height: ________________ (in./cm) Weight: _________________ (lb./kg)
Allergies: __________________________________________________________________________________
If you are not the member or the prescriber, you will need to submit a PHI Disclosure Authorization form with
this request which can be found at the following link:
https://magellanrx.com/member/external/commercial/common/doc/en-us/PHI_Disclosure_Authorization.pdf
MEMBER’S AUTHORIZED REPRESENTATIVE (IF APPLICABLE): ________________________________________
Authorized Representative Phone Number:
–
–
INSURANCE INFORMATION
Primary Insurance Name: Member ID Number:
Secondary Insurance Name: Member ID Number:
(Form continued on next page.)
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Prescription Drug Prior Authorization Form
© 2017–2021, Magellan Health, Inc. All rights reserved. MHID: MRXCOM01_01
Magellan Rx Management – Commercial Clients Revision Date: 01/01/2021 Page 2 of 4
Member’s Last Name: Member’s First Name:
PRESCRIBER INFORMATION
Prescriber’s Last Name: Prescriber’s First Name:
Prescriber’s Specialty: Email Address:
__________________________________________ _____________________________________________
National Provider Identifier (NPI) Number: DEA Number:
Office Phone Number: Office Fax Number:
–
–
–
–
Prescriber’s Address:
City: State: ZIP:
Requester (if different than provider):
Office Contact Person:
MEDICATION / MEDICAL AND DISPENSING INFORMATION
Drug Name/Form: __________________________________________________________________________
Dosing Frequency: __________________________________________________________________________
Length of Therapy: __________________________________________________________________________
Number of Refills: __________________________________________________________________________
Quantity per Day: ___________________________________________________________________________
New Therapy Renewal
If Renewal, what date was therapy initiated? ____________________________________________________
If Renewal, what was the duration of therapy (specific dates)? ______________________________________
(Form continued on next page.)
Prescription Drug Prior Authorization Form
© 2017–2021, Magellan Health, Inc. All rights reserved. MHID: MRXCOM01_01
Magellan Rx Management – Commercial Clients Revision Date: 01/01/2021 Page 3 of 4
Member’s Last Name: Member’s First Name:
MEDICATION / MEDICAL AND DISPENSING INFORMATION (CONTINUED)
How did the member receive the medication?
Paid Under Insurance
Insurance Name: ________________________________________________________________________
Prior Authorization Number (if known): ______________________________________________________
Other (explain): _________________________________________________________________________
Administration:
Oral/SL Topical
Injection IV Other:_____________________________
Administration Location:
Member’s Home Long Term Care Physician’s Office
Home Care Agency Ambulatory Infusion Center Outpatient Hospital Care
Other (explain):__________________________________________________________________________
DIAGNOSIS AND MEDICAL INFORMATION
1. Has the member tried any other medications for this condition?
Yes No
If Yes:
What was the medication therapy (specify drug name and dosage)?
______________________________________________________________________________________
What was the duration of therapy (specify dates)?
______________________________________________________________________________________
What was the response, reason for failure, or allergy?
______________________________________________________________________________________
2. What are the member’s diagnoses and ICD-10 codes?
Diagnoses: _____________________________________________________________________________
ICD-10 Codes: ___________________________________________________________________________
(Form continued on next page.)
Prescription Drug Prior Authorization Form
© 2017–2021, Magellan Health, Inc. All rights reserved. MHID: MRXCOM01_01
Magellan Rx Management – Commercial Clients Revision Date: 01/01/2021 Page 4 of 4
Member’s Last Name: Member’s First Name:
3. What additional clinical information do you have that is relevant to this request for a prior authorization?
Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or
increased dose and if the member has any contraindications for the health plan/insurer preferred drug.
Lab results with dates must be provided if needed to establish diagnosis or evaluate response. Please
provide any additional clinical information or comments pertinent to this request for coverage, including
information related to exigent circumstances, or required under state and federal laws.
_______________________________________________________________________________________
Attachments
Attestation: I attest the information provided is true and accurate to the best of my knowledge. 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 this form.
_____________________________________________________________ ________________________
Prescriber Signature (Required) Date
(By signature, the Physician confirms the above information is accurate and verifiable by patient records.)
Fax this form to: 1-800-424-3260
Mail requests to:
Magellan Rx Management Prior Authorization Program
c/o Magellan Health, Inc.
4801 E. Washington Street
Phoenix, AZ 85034
Phone: 1-800-424-3312
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Prescription Drug Prior Authorization Form MEMBER INFORMATION

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Completed 24 January 2022

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