Form Fa 63 – Fill Out and Use This PDF

The FA 63 form serves as a Prior Authorization Request for Nevada Medicaid, specifically concerning OptumRx Preferred Drug List (PDL) Exceptions for non-preferred drugs. It is a critical document for healthcare providers who wish to prescribe medications not listed as preferred within certain drug categories, ensuring that patients have access to necessary treatments not typically covered. To streamline the authorization process for non-preferred medication under Nevada Medicaid, consider filling out the FA 63 form by clicking the button below.

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Form Fa 63 PDF Details

In the intricate web of healthcare provisioning, navigating the authorization process for medication not listed on Nevada Medicaid's Preferred Drug List (PDL) is a challenge that demands scrupulous attention to detail. The FA-63 form emerges as a critical tool in this labyrinth, serving as a request for prior authorization for such non-preferred drugs. Its primary aim is to meticulously document the necessity for non-listed medication, ensuring that individuals receive the required treatment while adhering to the stringent guidelines laid down by Medicaid. This process intricately involves detailing the patient’s medical history, specifically focusing on any allergies, side effects, or unsuccessful attempts with preferred medications, thereby making a compelling case for the exception. Furthermore, it encompasses an assertion from the prescribing provider, through a certification, affirming the indispensability and suitability of the requested medication for the patient's condition, as sanctioned by Nevada Medicaid’s criteria. This comprehensive approach, while safeguarding fiscal resources, also puts a spotlight on the patient's health needs, ensuring they are met effectively and efficiently.

Question	Answer
Form Name	Form Fa 63
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	bcbs of ohio prior authorization form, anthem bcbs ohio prior authorization list, bcbs of ohio prior authorization, anthem bcbs prior authorization form pdf ohio

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Prior Authorization Request

Nevada Medicaid – OptumRx

PDL Exception (Non-Preferred Drugs)

Submit fax request to: 855-455-3303

Purpose: The Nevada Medicaid Preferred Drug List (PDL) lists “preferred” drugs in specific drug categories. Prior

authorization is required for non-listed drugs within these categories.

Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.

DATE OF REQUEST:

RECIPIENT INFORMATION

Last Name, First Name, Middle Initial:				Date of Birth:

Recipient ID:		Gender: Male Female		Phone:

PRESCRIBING PROVIDER INFORMATION
Name:			NPI:

Phone:			Fax (required):

Person to contact regarding this request:

DIAGNOSIS AND REQUESTED DRUG
Applicable ICD-10 code and diagnosis or symptom/side effect (REQUIRED):
Name:	Strength:				Generic substitution not permitted

Dosage:	Duration:

CLINICAL INFORMATION

Explain recipient’s history of allergies or unacceptable side effects experienced with preferred (PDL) medications.

List the preferred (PDL) medications that were tried and failed for the given diagnosis:

Drug Name	Reason for Failure	Date(s)
__________________________	__________________________________	_____________________
__________________________	__________________________________	_____________________

List any contraindications to or potential drug-drug interactions with the preferred (PDL) medications.

Additional Clinical Information (if applicable):

Please check the applicable boxes to indicate each item as true for the recipient:

The non-preferred drug is being requested for a unique indication that is supported by peer-reviewed literature or FDA-approved indication that is unique to the requested drug (document diagnosis above).

The member was recently discharged from a mental health facility on the requested medication. Date:_________

PROVIDER CERTIFICATION – Prescriber’s signature and date required.

I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by Nevada Medicaid.

Prescriber’s Signature:

Date:

This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.

FA-63
05/11/2017 PV11/19/2013	Page 1 of 1

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2. When the last segment is finished, you should insert the necessary specifics in Drug Name, Reason for Failure, Dates, List any contraindications to or, Additional Clinical Information if, Please check the applicable boxes, The nonpreferred drug is being, The member was recently discharged, PROVIDER CERTIFICATION, Date, and This authorization request is not so that you can move forward to the third step.

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Form Fa 63 – Fill Out and Use This PDF

Form Fa 63 PDF Details

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