Hospital:
II.
PRESCRIBER INFORMATION (*REQUIRED FIELDS)
*Name:
Specialty:
*NPI or DEA
Address:
City, State, Zip:
*Phone:
*Fax:
Group or
Office Contact
(*REQUIRED FIELDS)
Birth:
Phone:
Phone:
Allergies:
same
NOTE: Appropriate clinical information to support this request is required for all PA’s. Attach additional sheets if more space is needed.
MEDICATION PRIOR AUTHORIZATION REQUEST FORM
Is the request for a NON-SPECIALTY MEDICATION DISPENSED BY A PHARMACY?
□ YES → Complete THIS form and FAX to 1-866-399-0929
□ NO →Do NOT use this form. Complete the Drug-Specific Form (Link) form OR the Prior Authorization Form - Specialty Pharmacy and
Buy & Bill Form (Link).
TOD Y’S DATE: !
I. MEMBER INFORMATION (*REQUIRED FIELDS)
*Name:
ID Number:
Gender:
*Date of
Address:
City, State, Zip:
Primary
Alternate
Medication
III. Drug Information (only ONE drug request per form)
*Drug Name:
*Dosage Form:
*Strength:
*Directions for Use:
*
Therapy Start Date:
*
Therapy End Date:
IV. DIAGNOSIS (as relevant tothis request) (*REQUIRED FIELDS)
Diagnosis:
*ICD10:
Date of Diagnosis:
NOTE: Include diagnostic clinicals (labs, radiology, etc.).
V. MEDICATIONHISTORY (for this diagnosis)
A. Is the member currently onthis medication? ☐Yes; if yes, how long? ☐No; if no, skip items B&C, go toD.
B. Is this a request for continuation of a previous approval?
☐Yes; if yes, go to item C. ☐No; if no, skip item C, go toD.
C. Has the strength, dosage, or quantity required per day:
☐INCREASED: ☐DECREASED: ☐Remained the
D. Indicate PREVIOUS medications treatment/outcomes below.
NOTE: Confirmation will be made using claims history.
Drug Name, Strength, and Dosage Dates of
Therapy
Reason for
Discontinuation
1
2
3
4
VI.RATIONALEFORREQUESTandPERTINENTCLINICALINFORMATION
Prescriber Signature – Dispense asWritten (DAW): PrescriberSignature – Substitution Permitted:
Date: X Date:
Please access www.SunshineHealth.com or contact provider services for a current listing of preferred products. Incomplete and illegible forms will delay processing. Be sure to
include lab reports with requests when appropriate.
To request a 72 hour emergency supply of medication you may call Envolve Pharmacy Solutions at (877) 397-9526. NOTE: The 72 hour supply does not apply to specialty medications.
Requests can also be mailed to: Envolve Pharmacy Solutions, Attention: Prior Authorization Department, 5 River Park Place East, Suite 210, Fresno,California 93720.
*REQUIRED FIELDS - PA requests with missing/incomplete required fields may be returned as an invalid request. Valid requests also require appropriate clinical
documentation to support the medical necessity of this request.
X
Number:
Name:
