Us Script Prior Form PDF Details

Navigating the complexities of acquiring necessary medication can often be challenging, especially when prior authorization is required. The Medication Prior Authorization Request Form for the Sunshine State Health Plan, Florida, represents a crucial step in this process for many patients and healthcare providers. The purpose of this form is multifaceted, facilitating the approval of prescribed medications not immediately available without prior approval from insurance companies. By providing detailed information such as provider and member specifics, drug name, dosage, and relevant medical history, this document serves as a communication bridge between healthcare providers and insurance entities. The detailed sections requiring provider and medication information underscore the thoroughness needed to justify medical necessity. The form also contains instructions for its submission, either by fax or mail, and provides a contact number for requests concerning a 72-hour emergency supply of medication. It is designed to streamline the request for medication approval by ensuring all pertinent information is collated and presented at once, which is essential for timely processing. Additionally, the form prompts for rationale and pertinent clinical information, reinforcing the requirement for a clear demonstration of medical necessity. This form is an integral part of the healthcare process, striving to ensure patients receive the medications they need while navigating the insurance protocols efficiently.

QuestionAnswer
Form NameUs Script Prior Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessure scripts prior auth, surescripts pa form, surescripts prior auth, health medication prior authorization form

Form Preview Example

MEDICATION PRIOR AUTHORIZATION REQUEST FORM

Sunshine State Health Plan, Florida

(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 Sunshine State Health Plan Preferred Drug List (PDL) is available on the Sunshine State Health Plan website at www.sunshinestatehealth.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 Us Script Prior Form Online for Free

It's a breeze to complete the plan medication form. Our PDF tool was designed to be easy-to-use and allow you to fill out any PDF efficiently. These are the basic steps to go through:

Step 1: Locate the button "Get Form Here" and press it.

Step 2: It's now possible to edit the plan medication form. The multifunctional toolbar permits you to add, delete, change, and highlight content or perform other sorts of commands.

If you want to complete the plan medication form PDF, enter the content for all of the sections:

filling in surescripts prior authorization form pdf stage 1

Complete the C Has strength dosage or quantity, yes go to item D, no skip item D indicate rationale, D Please indicate previous, Dates of Therapy, Reason for Discontinuation, NOTE Confirmation of use will be, and IV Rationale for Request section with all the details asked by the application.

stage 2 to entering details in surescripts prior authorization form pdf

The system will request for more info to automatically prepare the area Appropriate clinical information, Provider Signature, Date, US Script will respond via fax or, and Contact Caremark at for.

part 3 to completing surescripts prior authorization form pdf

Step 3: Press the Done button to save the document. So now it is readily available for export to your gadget.

Step 4: It may be simpler to save duplicates of the form. You can be sure that we are not going to disclose or check out your information.

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