Illinicare Prior Authorization Form PDF Details

When faced with the need to prescribe medication that requires prior approval, healthcare providers must navigate through specific processes set by health insurance plans. The IlliniCare Prior Authorization form serves as a critical tool in this process for providers under the IlliniCare Health Plan in Illinois, ensuring that patients receive necessary medications in a timely manner. This form, which must be faxed to 866-399-0929 or mailed to the designated address, is meticulously designed to collect comprehensive information regarding the patient, the medication in question, and the medical rationale behind its prescription. Key sections of the form include Provider Information, Member Information, Drug Information, and a vital section on the Rationale for Request/Pertinent Clinical Information. All these sections together aid in assessing the medical necessity of the requested medication, adhering to IlliniCare's commitment to patient care. Notably, the form distinguishes itself by excluding biopharmaceutical products, guiding providers to contact Caremark for such medications, and mandates the inclusion of relevant lab reports to support requests. Ensuring all parts of the form are accurately completed is paramount; incomplete submissions can lead to processing delays. With a promise of a response within 24 hours barring weekends and holidays, and a provision for an immediate 72-hour medication supply in urgent cases, the IlliniCare Prior Authorization form exemplifies a structured yet patient-centric approach to healthcare management.

QuestionAnswer
Form NameIllinicare Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesprior, illinicare prior auth form, illinicare prior authorization form pdf, illinicare prior authorization

Form Preview Example

MEDICATION PRIOR AUTHORIZATION REQUEST FORM

IlliniCare Health Plan, Illinois

(Do Not Use This Form for Biopharmaceutical Products*)

FAX this completed form to 866-399-0929

OR Mail requests to: US Script PA Dept / 2425 West Shaw Avenue / Fresno, CA 93711

Call 800-460-8988 to request a 72-hour supply of medication.

I. Provider Information

 

 

II. Member Information

 

 

 

 

 

 

 

 

 

 

Prescriber name (print):

 

 

Member name:

 

 

 

 

 

 

 

 

 

 

Prescriber Specialty:

 

 

Identification number:

 

 

 

 

 

 

 

 

 

 

 

Fax:

 

Phone:

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

Office Contact Name:

 

 

Medication allergies:

 

 

 

 

 

 

 

III. Drug Information (One drug request per form)

 

 

 

Drug name and strength:

 

Dosage form:

Dosage interval (sig):

Qty per Day:

 

 

 

 

 

 

 

 

Diagnosis relevant to THIS request:

 

 

 

 

 

 

 

 

 

 

 

 

Expected length of therapy:

 

 

 

 

 

 

 

 

 

 

 

 

Medication History for this Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

A. Is member currently treated on this medication?

 

 

 

 

 

yes; How Long?_______________ [go to item B]

no

[skip items B & C; go to item D]

 

 

 

 

 

 

 

 

B. Is this request for continuation of a previous approval?

 

 

 

 

 

yes

[go to item C]

no

[skip item C; go to item D]

 

 

 

 

 

 

C. Has strength, dosage, or quantity required per day increased or decreased?

 

 

 

yes

[go to item D]

no

[skip item D; indicate rationale for continuation in Section IV and submit form]

 

 

 

 

 

 

 

D. Please indicate previous treatment and outcomes below.

 

 

 

 

 

Drug Name

 

 

Dates of Therapy

 

 

Reason for Discontinuation

 

(include strength and dosage)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The IlliniCare Health Plan Preferred Drug List (PDL) is available on the IlliniCare Health Plan website at www.illinicare.com .

IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)

Appropriate clinical information to support the request on

Provider Signature:

Date:

the basis of medical necessity must be submitted.

 

 

 

 

 

US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.)

*Contact Caremark at 800-237-2767 for Biopharmaceutical Products.

How to Edit Illinicare Prior Authorization Form Online for Free

We've used the endeavours of the best computer programmers to make the PDF editor you are about to work with. Our software will allow you to prepare the illinicare prior authorization form without any difficulty and don’t waste your time. All you have to do is stick to the next quick tips.

Step 1: To get started, hit the orange button "Get Form Now".

Step 2: When you've accessed the illinicare prior authorization editing page you can discover every one of the actions you can use concerning your template from the top menu.

In order to complete the file, type in the details the software will request you to for each of the appropriate sections:

example of blanks in authorization

The software will need you to fill in the NOTE Confirmation of use will be, IV Rationale for Request, Appropriate clinical information, Provider Signature, Date, US Script will respond via fax or, and Contact Caremark at for segment.

stage 2 to finishing authorization

Step 3: Click "Done". You can now export your PDF form.

Step 4: Just be sure to create as many duplicates of your file as you can to stay away from potential problems.

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