Are you in need of medication but unable to get it due to a lack of insurance coverage? If so, then you may want to learn more about the HMS Quest Prior Authorization Form. This form is an important tool that can help those without insurance or with inadequate coverage access the medications they need for their treatment or health requirements. Knowing how and when to use this form can drastically reduce waiting time, save money on the cost of medications, and make sure your medical needs are met quickly. In this blog post we'll provide step-by-step instructions for completing the HMS Quest Prior Authorization Form, tips for success, and answer any questions you might have about using this helpful resource. Read on to find out what you need to know!
| Question | Answer |
|---|---|
| Form Name | Hmsa Quest Prior Authorization Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | hmsa prior authorization form, prior authorization form quest, custom design benefits prior auth form, prior authorization form quest medicaid |
Prior Authorization Criteria Form
08/06/2013
HMSA Quest (Medicaid)
HMSA QUEST (MEDICAID)
Campral (Medicaid)
This fax machine is located in a secure location as required by HIPAA regulations.
Complete/review information, sign and date. Fax signed forms to CVS/Caremark at
Please contact CVS/Caremark at
When conditions are met, we will authorize the coverage of Campral (Medicaid).
Drug Name (select from list of drugs shown)
Campral (acamprosate calcium)
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Patient Information |
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Patient Name: |
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Patient ID: |
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Patient Group No.: |
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Patient DOB: |
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Patient Phone: |
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Prescribing Physician |
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Physician Name: |
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Physician Phone: |
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Physician Fax: |
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Physician Address: |
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City, State, Zip: |
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Diagnosis: |
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ICD Code: |
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Comments: |
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Please circle the appropriate answer for each question.
1. |
Does the patient have a clinical diagnosis of alcohol |
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dependence? |
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[If the answer to this question is no, then no further questions required.] |
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2. |
Does clinical evidence indicate that the patient will abstain from |
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alcohol consumption for at least 5 days prior to treatment |
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initiation? |
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[If the answer to this question is no, then no further questions required.] |
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3. |
Does the patient have severe renal impairment (creatinine |
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clearance less than or equal to 30 mL/min)? |
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[If the answer to this question is yes, then no further questions required.] |
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4. |
Has a trial of oral or injectable naltrexone been attempted at a |
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N |
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clinically significant dosage and duration? |
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[If the answer to this question is yes, skip to question 6.] |
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5. |
Has therapy with naltrexone been documented to be clinically |
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N |
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inappropriate for this patient for reasons such as hepatic |
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Campral.html[8/8/2013 10:40:14 AM]
Prior Authorization Criteria Form |
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insufficiency or chronic pain medication use? |
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6. Will Campral administration be a part of a comprehensive |
Y N |
psychosocial treatment program for this patient? |
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I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature and Date
Campral.html[8/8/2013 10:40:14 AM]