Get Sunshine State Health Plan Medication Prior Authorization Request Form

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. 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 C. Has strength dosage or quantity required per day increased or decreased no skip item D indicate rationale for continuation in Section IV and submit form D. Please indicate previous treatment and outcomes below. Drug Name include strength and dosage Dates of Therapy Reason for Discontinuation 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. 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 C. Has strength dosage or quantity required per day increased or decreased no skip item D indicate rationale for continuation in Section IV and submit form D. Please indicate previous treatment and outcomes below. Drug Name include strength and dosage Dates of Therapy Reason for Discontinuation 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 the basis of medical necessity must be submitted* Provider Signature Date 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. 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. .