Are you in need of a form for Procrit? If so, the Silverscript Procrit Pa form may be what you are looking for. This form is designed to help those who need to take this medication. It is important that you understand how to use this form and what it is for before you begin using it. With that in mind, let's take a closer look at the Silverscript Procrit Pa form. What does the Form include? When looking at the Silverscript Procrit Pa form, there are a few things that stand out immediately. The first thing is that it includes detailed information on how to take this medication. It also includes information on when and how to contact your doctor if needed.
You can find information regarding the type of form you need to complete in the table. It can show you the time it should take to fill out silverscript procrit pa form, what fields you will have to fill in and several further specific facts.
| Question | Answer |
|---|---|
| Form Name | Silverscript Procrit Pa Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | silverscript prior auth, formulary form, silverscript request, silverscript pa form 2021 |
Fax completed form to:
Questions, please call:
24 hours a day 7 days a week (TTY users call: 711)
Important Information about Prescription Drug Coverage
To:From:
Fax:Pages:
Re: Request for Coverage of a
Please complete the attached Request for Coverage of a
To prevent delays in the review process please complete all requested fields.
Completed forms should be faxed to:
Information about this Request for Coverage of a
Use this form to request coverage of a drug that is not on the formulary. To process this request, documentation that all formulary alternatives would not be as effective or would have adverse effects is required. Please provide clinical information or other evidence supporting the medical necessity of the
You can make an expedited request by indicating this at the top of the attached form. If you request an expedited review and sign the attached form, you certify that applying the 72 hour standard review time frame may seriously jeopardize the life or health of the member or the member's ability to regain maximum function.
Information on the attached form is protected health information and subject to all privacy and security regulations under HIPAA.
Member privacy is important to us. Our employees are trained regarding the appropriate way to handle our members' private health information.
CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments.
Silverscript® Insurance Company |
Fax completed form to: |
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Questions, please call: |
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24 hours a day 7 days a week |
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(TTY users call: 711) |
Request for Coverage of a
Patient Information
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Prescriber and Pharmacy Information |
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All items below this line are for Physician Use Only |
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Information for Requested Drug |
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Drug Name: |
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Drug Requested is (circle one): Brand /Generic |
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Dosage form: |
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Qty per 30 days: |
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Drug is (circle one):Newly prescribed /Refill |
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Directions: |
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Diagnosis: |
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Standard Reviews will be completed in under 72 hours. An expedited |
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review is available if you certify that a standard review time frame will seriously jeopardize the health of your patient. To request an expedited review, simply indicate this at the top of this page.
Request for Coverage of a
Medical Justification: Please provide medical justification for the
If all formulary agents would not be effective, please specify prior treatment
If all formulary agents would have adverse effects, please specify prior adverse effect
If patient preference for nonformulary drug, please provide your clinical
If no available formulary alternatives have been previously tried, please check this box.
I attest that the information provided on this form is true and accurate as of this date:
Prescriber's signature: |
Date: |
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