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  • Ct Dss Drug Prior Authorization Request Form 2017

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Map.com and can be accessed by clicking on the pharmacy icon) 1. Prescriber s Name (Last, First) 5. Member s Name (Last, First) 2. Prescriber s NPI 6. Member s ID 3. Prescriber s Phone 7. Member s Date of Birth (MMDDCCYY) 4. Prescriber s Fax 8. Pharmacy s Fax 9. Drug Requested 10. Strength 11. Quantity 12. Frequency of Dosing Please complete only the section(s) that pertains to the type of PA being requested. Incomplete requests will be denied. 14. Early Refill Reque.

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Prior authorization in health care is a requirement that a provider (physician, hospital, etc.) obtains approval from your health insurance plan before prescribing a specific medication for you or performing a particular medical procedure.

The Connecticut Medicaid Preferred Drug List (PDL) is a listing of prescription products recommended by the CT Department of Social Services (DSS) Pharmaceutical and Therapeutics Committee. The drugs which are considered “preferred” have been selected for their safety, clinical significance, and efficiency.

Prior authorization requires the prescriber to receive pre-approval for prescribing a particular drug in order for that medication to qualify for coverage under the terms of the pharmacy benefit plan.

Prior Authorization is a cost-savings feature of your prescription benefit plan that helps ensure the appropriate use of selected prescription drugs. This program is designed to prevent improper prescribing or use of certain drugs that may not be the best choice for a health condition.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.

What is prior authorization? This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. If you don't get prior authorization, a medication may cost you more, or we may not cover it.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232