Fillable Request or Formulary Exception Form Fax to (701) (Sanford Health Plan)

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Request or Formulary Exception Form Fax to (701) (Sanford Health Plan)

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The Request or Formulary Exception Form Fax to (701) (Sanford Health Plan) form is 2 pages long and contains:

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Compliant with MN C-2.0 October 2015
HP-0663 04-19
Prescription Drug Prior Authorization (PA)
Request or Formulary Exception Form
Fax to (701) 234-4568
PO Box 91110
Sioux Falls, SD 57109-1110
Toll-Free: (855) 305-5062
TTY/TDD: (877) 652-1844
Fax: (701) 234-4568
INSTRUCTIONS:
1. Only request one (1) medication per form.
2. All fields must be completed and legible for review.
3. The Plan’s decision will be based on individual plan policy and clinical documentation submitted.
4. Fax completed form to the number above, or submit online through your provider portal at
sanfordhealthplan.com/providerlogin. Prior authorizations cannot be completed over the phone.
5. Questions? Contact Pharmacy Management Department at (855) 305-5062.
Please check the appropriate box below. This form is being used for:
☐
Formulary Exception
☐ Prior Authorization (PA) Request
☐ Unsure/Unknown
Member Information
Date of Birth:
Member ID #:
Drug Allergies:
Provider Information
Billing Facility Information (if applicable)
Prescriber name (first & last):
☐ MD
☐ DO
☐ PA
☐ NP
☐ APRN
☐ _________
Facility Name:
Specialty:
NPI #:
Tax ID #:
NPI #:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone:
Fax:
Phone:
Fax:
Contact person at
provider’s office:
Contact person
at facility:
Prescription Drug Information
Medication being requested:
Strength:
Quantity:
Day’s Supply:
HCPC
(if applicable):
Directions for use:
Requested therapy medication is:
☐ New ☐ Continuation of therapy
Expected length of therapy:
Check here if this request is for retroactive coverage
for a previous claim or date of service.
Date of service: ______________________
** If continuation,
provide start date: __________________
Medical rationale for use:
Diagnosis
PRIMARY DIAGNOSIS (ICD-10 CODE):
SECONDARY DIAGNOSIS (ICD-10 CODE):
DESCRIPTION:
DESCRIPTION:
Questions? Contact Pharmacy Management Department at (855) 305-5062 | TTY/TDD (877) 652-1844
For free translation service, call (800) 892-0675
Compliant with MN C-2.0 October 2015
HP-0663 04-19
Prescription Drug Prior Authorization (PA) Request or Formulary Exception Form (page 2)
Clinical Information Submitted for Determination
• The specific records needed for review must be attached. Denote below which pages of the records to
review to help expedite the review process.
• If you are a Sanford Health provider and would like the Plan to review clinical documentation in One
Chart (the patient’s electronic medical record), the dates and descriptions of specific records t
o
r
eference must be indicated below.
Current clinical notes
Labs
Other
Other medical
conditions to consider:
If the request is for a formulary exception, explain why the preferred medication(s) would not meet
the Member’s needs:
Previous Therapies
• List all current and past therapies the Member has tried specific to the diagnosis.
•
NOTE: “see chart” is not acceptable documentation for this section.
Medications/Therapies
(Drug name, strength, & dosing schedule)
Dates of Therapy/
Treatment Duration
Outcome of Therapy or Reason for Discontinuation
(Describe any adverse reactions or efficacy failure)
• All fields must be completed and legible for review.
• The Plan’s decision will be based on individual plan policy and clinical documentation submitted.
• Fax completed form to (701) 234-4568 or submit the request online in the Provider Portal at
s
anfordhealthplan.com/providerlogin.
• Prior authorizations cannot be completed over the phone.
Signature
Requesting Person/Authorized
Representative Signature:
Printed Name:
Date Submitted:
Questions? Contact the Pharmacy Management Department at (855) 305-5062 | TTY/TDD (877) 652-1844
For free translation service, call (800) 892-0675
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Request or Formulary Exception Form Fax to (701) (Sanford Health Plan)

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Completed 20 May 2021

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