Envision Rx Prior Auth PDF Details

The Envision Rx Prior Authorization Request Form represents a critical step in the process of obtaining certain prescribed medications. Managed by EnvisionRx Options, this form plays a pivotal role in ensuring patients have access to necessary, but sometimes costly, medications under their pharmacy drug benefit plan. Physicians are required to fill out detailed information about the patient, including their name, member number, date of birth, diagnosis, and the specific medication requested, along with its dosage and intended duration of therapy. The form also asks whether the medication request is for initial or continuing therapy and requires a detailed account of any previous medications tried by the patient, including the outcomes of these treatments. For medications requested for off-label use, the prescribing physician must provide supporting evidence from a peer-reviewed journal to back up the request. The urgency of the medication request can also be indicated. All this information is then reviewed by EnvisionRx to determine coverage eligibility, making it essential that all sections of the form are completed accurately to avoid delays. The prior authorization process aims to verify the necessity of the prescribed medication, ensuring it aligns with the patient’s health benefit plan while also considering cost-effectiveness and safety. This cumbersome but necessary procedure underscores the balance between patient care and the prudent use of healthcare resources.

QuestionAnswer
Form NameEnvision Rx Prior Auth
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesenvisionrx prior authorization form, envisionrxoptions prior form, envisionrxoptions prior authorization request, envisionrxoptions prior authorization form

Form Preview Example

PRIOR AUTHORIZATION REQUEST FORM

EOC ID:

EnvisionRx General Prior Authorization- 1

Phone: 866-250-2005 Fax back to: 877-503-7231

ENVISION RX OPTIONS manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process.

Patient Name:

Member Number:

Date of Birth:

Group Number:

Address:

City, State, Zip: Member Phone:

Prescriber Name:

 

Fax:

Phone:

Office Contact:

 

NPI:

State Lic ID:

Address:

 

City, State, Zip:

 

Drug Name:

Expedited/Urgent

Directions:

Please attach any pertinent medical history or information for this patient that may support approval. Please answer the

following questions and sign:

Q1. Is this request for initial or continuing therapy?

Initial therapy

Continuing therapy (Start date MM/YY):

Q2. Please indicate the patient's diagnosis for the requested medication:

Q3. What is the quantity of medication that is being requested per 30 days?

Q4. What is the anticipated duration of therapy?

Less than one month

One to three months

Three months to one year

Lifetime

Q5. Please list all other medications the patient has previously tried for the indicated diagnosis along with the dates and outcomes (e.g. ineffective, adverse reaction, etc):

Q6. IF THE REQUEST IS FOR OFF-LABEL USE you must provide a unique peer-reviewed journal article to support the request. Please attach any medical information that may support approval.

Physician Signature

Date

This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for the return of this document.

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How to Edit Envision Rx Prior Auth Online for Free

It is a piece of cake to complete the envision rx. Our PDF editor was meant to be assist you to fill in any document easily. These are the steps to follow:

Step 1: Press the "Get Form Now" button to begin.

Step 2: At the moment, you can start modifying the envision rx. The multifunctional toolbar is at your disposal - add, remove, adjust, highlight, and undertake many other commands with the content in the document.

Enter the requested information in each one area to complete the PDF envision rx

envisionrxoptions prior authorization form fields to fill in

Include the essential details in the Q What is the anticipated duration, Q IF THE REQUEST IS FOR OFFLABEL, Physician Signature, Date, and This telecopy transmission section.

envisionrxoptions prior authorization form Q What is the anticipated duration, Q IF THE REQUEST IS FOR OFFLABEL, Physician Signature, Date, and This telecopy transmission fields to fill

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