Illinicare Prior Authorization Form Pdf Details

If you are like most people, you have probably never heard of Illinicare prior authorization form. However, if you are one of the millions of Americans who rely on Medicaid or Medicare for your health care coverage, then this form is something that you should be familiar with. The Illinicare prior authorization form is used by both Medicaid and Medicare to determine whether or not a particular service or treatment is covered under your health care plan. In order to get the most out of your health care coverage, it is important to understand how the Illinicare prior authorization form works and how to use it correctly.

Below is the information regarding the file you were looking for to fill in. It can tell you the amount of time you'll need to finish illinicare prior authorization form, what fields you need to fill in, etc.

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

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.

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