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How to fill out the PHP-187C online
The PHP-187C is a prescription drug prior authorization request form that must be completed accurately to avoid processing delays. This guide will walk you through each section of the form, ensuring that you have the necessary information to fill it out correctly.
Follow the steps to complete the PHP-187C online.
- Click the ‘Get Form’ button to access the PHP-187C form and open it for completion.
- In the 'Patient Information' section, enter the patient's name, member ID, and date of birth accurately.
- Proceed to the 'Requesting Provider Information' section. Fill in the requesting physician/provider's name, NPI, specialty, tax ID number, address, phone number, fax number, contact name, and their phone and fax numbers.
- Complete the 'Pharmacy Information' section by providing the pharmacy name, phone number, and fax number.
- In the 'Drug Information' section, enter the requested drug name and strength, quantity needed, ICD-9 code, usage directions, length of therapy, and diagnosis.
- List any previous drugs that the patient has tried in the space provided. Make sure to provide the drug name and dosage.
- Provide a medical rationale for the requested drug. Include relevant chart notes and supporting lab results, as well as a justification for why a formulary alternative is not acceptable.
- Lastly, the requesting provider must sign and date the form to ensure it is valid.
- After completing the form, save your changes, then download, print, or share the completed PHP-187C form as needed.
Complete your prescription drug prior authorization request online with the PHP-187C.
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