Get 14100 Magellan Plaza Form

Alaska Medicaid / Prior Authorization Request Form Prescriber Use Only Fax this request to 888 603-7696 Questions Call Magellan Medicaid Administration at 800 331-4475 Or mail this request to Medicaid PA Unit 14100 Magellan Plaza Maryland Heights MO 63043 Form available http //dhss. alaska*gov/dhcs/Pages/pharmacy/medpriorauthoriz. aspx Note / Product PA s can only be requested using this form* Approval does not ensure eligibility. Please verify Medicaid eligibility before completing this form* REQUESTOR RECIPIENT Must be requested by prescriber. See below. Requestor Name Print Last Name First Name Middle I. DOB Medicaid ID mm/dd/yyyy 10-digits PRESCRIBER Name Revised 1-2013 Phone Sex Male Female NPI Fax Specialty DEA Doses 3 units per day OR 24 mg per day will NOT be approved* Only 1 strength of 1 product will be authorized for use at a given time. Check one Box SL Tab 2mg sublingual film 2mg/0. 5mg SL Tab 2mg/0. 5mg Quantity Sig RATIONALE FOR PRIOR AUTHORIZATION Primary Diagnosis ICD-9 Check all that apply The patient is at least 16 years old. The patient is being treated for opioid dependence and has agreed to adhere to a treatment plan* The physician meets all qualifications State and Federal to prescribe products for treatment of opioid addiction* The physician has explained the risks of using products with benzodiazepines alcohol tranquilizers and narcotic analgesics to the patient. PHYSICIAN S SIGNATURE DATE PRESCRIBER S DATA 2000 WAIVER DEA Drug Addiction Act of 2000 All sections must be completed or the request will not be approved Confidentiality Notice The documents accompanying this transmission contain confidential health information that is legally privileged* If you are not the intended recipient you are hereby notified that any disclosure copying distribution or action taken in reliance on the contents of these documents is strictly prohibited* If you have received this information in error please notify the sender Via return FAX immediately and arrange for the return or destruction of these documents 2010 Magellan Medicaid Administration Inc* All rights reserved* Effective 09/01/2010. alaska*gov/dhcs/Pages/pharmacy/medpriorauthoriz. aspx Note / Product PA s can only be requested using this form* Approval does not ensure eligibility. Please verify Medicaid eligibility before completing this form* REQUESTOR RECIPIENT Must be requested by prescriber. Please verify Medicaid eligibility before completing this form* REQUESTOR RECIPIENT Must be requested by prescriber. See below. Requestor Name Print Last Name First Name Middle I. DOB Medicaid ID mm/dd/yyyy 10-digits PRESCRIBER Name Revised 1-2013 Phone Sex Male Female NPI Fax Specialty DEA Doses 3 units per day OR 24 mg per day will NOT be approved* Only 1 strength of 1 product will be authorized for use at a given time. See below. Requestor Name Print Last Name First Name Middle I. DOB Medicaid ID mm/dd/yyyy 10-digits PRESCRIBER Name Revised 1-2013 Phone Sex Male Female NPI Fax Specialty DEA Doses 3 units per day OR 24 mg per day will NOT be approved* Only 1 strength of 1 product will be authorized for use at a given time. Check one Box SL Tab 2mg sublingual film 2mg/0. 5mg SL Tab 2mg/0. 5mg Quantity Sig RATIONALE FOR PRIOR AUTHORIZATION Primary Diagnosis ICD-9 Check all that apply The patient is at least 16 years old.