Get Specialty Medication Prior Authorization Form - Peach State Health Plan

Filling out the Specialty Medication Prior Authorization Form for Peach State Health Plan is an essential step in ensuring that patients receive the medications they need in a timely manner. This guide provides a clear, step-by-step approach to completing the form online.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the patient information section by entering the patient's name, address, city, state, zip code, home phone, alternate phone, date of birth, and gender. Ensure all details are accurate and up to date.
3. Provide the prescriber information, which includes the prescriber name, specialty, NPI number, group or hospital affiliation, address, city, state, zip code, phone, fax, and a contact name. This information is critical for verification.
4. Input the insurance information by listing both primary and secondary insurance details. Include the identification numbers and phone numbers for both insurance providers.
5. Detail the statement of medical necessity, which requires the diagnosis, including the ICD-9 code and its description. Provide the date of diagnosis and include supporting clinical documentation, such as lab results or radiology reports.
6. Indicate whether the member is currently treated with the requested medication and if this request continues a previous approval by Peach State. Additionally, specify any changes in strength, dosage, or quantity.
7. List the medication(s) requested, including their strength, dosage, directions for use, quantity, and number of refills. Additionally, provide the therapy start date.
8. Finally, ensure to obtain the prescriber’s signature, which is essential for the authorization process.
9. After completing the form, save your changes, download a copy, print it for records, or share it as necessary.

Take the necessary steps to complete your Specialty Medication Prior Authorization Form online today.