Fillable Specialty Pharmacy Medical Request

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Specialty Pharmacy Medical Request

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The Specialty Pharmacy Medical Request form is 2 pages long and contains:

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  • 26 check-boxes
  • 98 other fields

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File type: PDF

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Specialty Pharmacy Medical Request
P
F
E
1 Month 3 Months 6 Months Other
Initial Continuation of Care Appeal
Address City State
Home Phone Work Phone Cell Phone
DOB Height Weight Allergies
ID # Group # Insured Phone
Medicare? If yes, provide # Medicaid? If yes, provide #
Yes No Yes No
Policy # Group # Insured Phone
Current medications as well as medications that have been TRIED/FAILED. (Required)
Zip
SECTION B - INSURANCE INFORMATION
PO Box 909786-60690
Chicago, IL 60690-9786 SpecialtyRx@alliedbenefit.com
312-281-1636
All relevant information must be completed. Allied's receipt of this completed form does not constitute a guarantee of benefits.
SECTION A - PATIENT INFORMATION
12 Months
Any pertinent imaging reports, such as U/S, X-rays, CTs.
Please refer to the phone number
listed on the back of the member's ID
card.
Duration of Authorization:
Primary Insurance Pharmacy Benefit Manager
Patient's First Name Patient's Last Name
Allied Benefit Systems
Employee's SS#
Pharmacy Benefit Manager
Employee's First Name Employee's Last Name
Today's Date: Date Medication Needed:
Secondary Insurance
Request:
Letter of Medical Necessity. (Required)
3-6 months of clinical information including medical history, physical exams and most current progress notes. (Required)
Any pertinent lab work, including fecal occult blood test, culture reports, Hematocrit, Hemoglobin, Hormone studies and TSHs.
Copy of the Rx Order or Script. (Required)
When submitting a prior authorization request, please note the following information is necessary when applying criteria and determining
medical necessity:
Address City State Zip
Phone Fax St Lic. # NPI # DEA # UPIN
Primary Diagnosis ICD-10 Code Secondary Diagnosis ICD-10 Code
Frequency
Frequency
Frequency
Yes No
Yes No
Date
Physician's Office
SECTION C - PHYSICIAN INFORMATION
SECTION E - BILLING AND SHIPPING INFORMATION
Patient's Home Ambulatory Infusion Center (location address)
Physician's Office Home Care Agency (name and address if available)
Patient Administered Oral Patient Administered Injectable
All required sections must be completed in full to ensure covered prescriptions ship within 3-7 business days. If these sections are not
completed accurately, your order may be delayed.
Home Care Agency Ambulatory Infusion Center
Authorization Number (if required)
Dose/Strength
Is this Provider going to supply and bill for the medication?
Name: Phone Number:
If YES, is the Physician listed in section C the one billing for this medication?
Phone
HCPCS/CPT Code Directions Quantity # of Refills
Dose/Strength
Dose/Strength
First Name Last Name
Office Contact Name
Prescriber's Signature (required by law)
# of RefillsDirections Quantity
SECTION D - CURRENT MEDICAL INFORMATION ONLY
Administration Site:
If NO, please provide the name and phone number for the Physician or Facility supplying and billing for this medication.
Requested Medication Name Directions Quantity # of Refills
Tried and Failed Medications
pertaining to request above.
Shipping: (If shipping is required, please complete below.)
Patient's Home
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Specialty Pharmacy Medical Request

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Completed 20 January 2022

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